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MEDICAL  CLINIC 


BY  G.  ANDRAL, 

PROFESSOR  OF  THE  FACULTY  OF  MEDICINE  OF  PARIS,  MEMBER  OF  THE  ROYAL 
ACADEMY  OF  MEDICINE,  ETC.,  ETC. 


VOL.  I. 


DISEASES  OF  THE  ABDOMEN 


Digitized  by  the  Internet  Archive 
in  2016 


https://archive.org/details/medicalclinic01andr 


MEDICAL  CLINIC 


DISEASES  OE  THE  ABDOMEN. 


31 


G.  ANDRAL, 

PROFESSOR  TO  THE  FACULTY  OF  MEDICINE  OF  PARIS,  MEMBER  OF  THE  ROYAL  ACADEMY 
OF  MEDICINE,  ETC.,  ETC. 


CONDENSED  AND  TRANSLATED,  WITH  OBSERVATIONS, 

BY  D.  SPILLAN,  M.D., 

FELLOW  OF  THE  KINO  AND  QUEEN’S  COLLEGE  OF  PHYSICIANS  IN  IRELAND,  MEMBER  OF  THE  ASSOCIATION  OF 
THE  FELLOWS  AND  LICENTIATES  OF  THE  COLLEGE  OF  PHYSICIANS,  AND  FORMERLY 
# PHYSICIAN  TO  THE  DUBLIN  GENERAL  DISPENSARY. 


mnnwpm: 

ED.  BARRINGTON  & GEO.  D.  HASWELL. 

NEW  YORK  — J.  & H.  G.  LANGLEY:  CHARLESTON,  S.  C.  — WM.  H.  BERRETT. 
RICHMOND.  VA.  — SMITH,  DRINKER,  AND  MORRIS. 
LOUISVILLE,  KY.  — JAMES  MAXWELL,  JR. 

1 843. 


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DISEASES  OF  THE  ABDOMEN. 

PAGE 

Introduction  ....  . . . ■ . . 5 

BOOK  I.  Diseases  of  the  Digestive  Tube  .....  13 

Section  I.  Observation  on  Fevers  ......  13 

Chap.  I.  Continued  Fevers  terminating  in  Death  ....  15 

Art.  1.  Continued  Fevers  connected  with  Follicular  Inflammation  of  the  Intes- 
tines . . . . . . . 16 

§ 1.  Observations  on  Follicular  Enteritis  at  the  Period  of  the  Exantheme  16 

§ 2.  Observations  on  Follicular  Enteritis  at  the  Period  of  Ulceration  . 32 

Art.  2.  Continued  Fever  connected  with  other  forms  of  Gastro-intestinal  Le- 
sion than  Follicular  Enteritis  .....  78 

Art.  3.  Observations  on  Cases  of  Different  Diseases,  accompanied  with  Ty- 
phoid Symptoms,  without  any  appreciable  Lesion  of  the  Digestive 
Tube  ....... 

§ 1.  Typhoid  Symptoms  developed  in  consequence  of  different  Lesions 
appreciable  by  Anatomy  .... 

$ 2.  Typhoid  Symptoms  without  Lesions  appreciable  by  Anatomy 
Chap.  II.  Continued  Fevers  terminating  in  return  to  Health 
Art.  1.  Treatment  by  Diet  and  Simple  Diluents  . 

Art.  2.  Treatment  by  Evacuants  .... 

Art.  3.  Treatment  by  Antiphlogistics  .... 

Art.  4.  Treatment  by  Tonics  ..... 

Chap.  Ill,  Recapitulation  ...... 

Art.  1.  Etiology.  ...... 

Art.  2.  State  of  the  Different  Organs  after  Death  and  during  Life 
Digestive  Tube  ....... 

I.  Lesions  found  after  death  in  the  Digestive  Tube 

A.  Constancy  of  the  Lesions  of  the  Digestive  Tube  . 

B.  Frequency  of  the  Lesions  of  the  Digestive  Tube 

C.  Seat  and  nature  of  the  Lesions  of  the  Digestive  Tube 

a.  Stomach  ....... 

b.  Small  intestine  ...... 

c.  Large  intestine  . . 

d.  Matters  contained  in  the  Digestive  Tube 

D.  Connexion  between  the  Gastro-intestinal  Lesions  and  the  Symptom 
§ 1.  Functional  Lesions  of  the  Digestive  Apparatus  . 

Circulatory  Apparatus 

§ 1.  Lesions  found  after  Death  in  the  Circulatory  Apparatus 
§ 2.  Lesions  of  the  Circulatory  Apparatus  observed  during  life  . 

Apparatus  of  the  Lymphatic  Circulation 

Respiratory  Apparatus  ...... 

§ 1.  Lesions  of  this  Apparatus  observed  after  Death 
§ 2.  Lesions  of  the  Respiratory  Apparatus  observed  during  Life 
Apparatus  of  the  Secretions  . 

§ 1.  Lesions  of  the  Cellular  Tissue  .... 

§ 2.  Lesions  of  the  Serous  Membranes 

§3.  Lesions  of  the  Biliary  Apparatus  .... 

§4.  Lesions  of  the  Urinary  Apparatus 
§ 5.  Lesions  of  the  Salivary  Glands  and  Pancreas 
Apparatus  of  the  Life  of  Relation  .... 


§ 1.  Lesions  of  those  Organs  observed  after  Death 

A.  Nervous  Centres  . 

B.  The  Muscles  ..... 

§ 2.  Lesions  of  those  Organs  observed  during  Life  . 

A.  Lesions  of  the  Functions  of  the  Nervous  Centres 

B.  Lesions  of  Muscular  Action  .... 

C.  Lesions  of  the  Functions  of  the  Organs  of  the  Nerves 


87 

88 
102 
106 
107 
111 
113 
121 
131 
131 
134 
134 
134 
134 
136 
136 
136 
138 
145 

145 

146 

147 
161 
161 
171 
176 
176 
176 
178 
180 
180 
181 
181 

183 

184 

185 
185 
185 
188 
188 
188 

190 

191 


885947 


4 


CONTENTS. 


PAGE 

Art.  3.  Treatment  .......  197 

§ 1.  Treatment  by  Diet  and  Mucilaginous  or  Acidulated  Drinks  • 198 

§ 2.  Treatment  by  Bloodletting  .....  201 

§3.  Treatment  by  Evacuants  ......  206 

§ 4.  Treatment  by  Tonics  and  Stimulants  ....  210 

Section  II.  Diseases  of  the  Digestive  Tube  in  which  Local  Symptoms  alone 

exist,  or  in  which  they  predominate  . . . .211 

Chap.  I.  Observations  on  Acute  Gastritis  .....  212 

Chap.  II.  Observations  on  Chronic  Gastritis.  ....  222 

Art.  1.  Alterations  produced  in  the  Stomach  by  Chronic  Gastritis  . 223 

§ 1.  Alterations  of  the  Mucous  Membrane  ....  224 

§ 2.  Alterations  of  the  Tissues  subjacent  to  the  Mucous  Membrane  240 

Art.  2.  Symptoms  of  Chronic  Gastritis  .....  263 

Art.  3.  Treatment  of  Chronic  Gastritis  ....  274 

fhap.  III.  Observations  on  some  Affections  of  the  Stomach  not  Inflammatory  275 

Chap.  IV.  Observations  on  Lead-colic  and  other  Affections  resembling  it  287 

Art.  1.  State  of  the  Digestive  Tube  in  persons  who  died  with  Colic  . 288 

Art.  2.  Symptoms  of  Lead-colic  .....  291 

Art  3.  Treatment  of  Lead-colic  293 

A,  Employment  of  Strychnine  .....  295 

B.  Employment  of  Brucine  . .....  297 

Art.  4.  Nature  of  Lead-colic  ......  298 

Art.  5.  Observations  on  some  morbid  states,  bearing  some  analogy  to  symp- 
toms, &c.,  of  Lead-colic  .....  298 


3i 


BOOK  II.  Diseases  of  the  Liver  and  its  Appendages  ....  300 

Section  I.  Diseases  of  the  Parenchyma  of  the  Liver  . . . 300 

Chap.  I.  Lesions  found  in  the  Liver  after  Death  ....  300 

Chap.  II.  Symptoms  of  Diseases  of  the  Liver  ....  307 

Art.  1.  Local  Symptoms  of  Diseases  of  the  Liver  ....  307 

Art.  2.  General  or  Constitutional  Symptoms  ....  322 

§ 1.  Disturbances  of  Digestion  ......  323 

§ 2.  Disturbances  of  Circulation  ...  . 327 

A.  Sympathetic  Disturbances  of  the  Circulation  . . . 327 

B.  Disturbances  of  the  Circulation  occasioned  by  an  Obstacle  to  the 

free  Circulation  within  the  Liver  ....  329 

§ 3.  Disturbances  of  the  Secretions  and  of  Nutrition  . . . 333 

Chap.  III.  Cases  ........  334 

Art.  1.  Sanguineous  Congestions  of  the  Liver  ....  335 

Art.  2.  Alteration  of  Nutrition  in  the  Parenchyma  of  the  Liver  . . 345 

§ 1.  Observations  on  Hypertrophy  of  the  Liver  . . . 345 

§2.  Observations  on  Softening  of  the  Liver  ....  348 

§ 3.  Observations  on  Induration  of  the  Liver  ....  352 

§ 4.  Observations  on  Atrophy  of  the  Liver  ....  356 

Art.  3.  Observations  on  Accidental  Productions  in  the  Liver  . . 361 

§ 1.  Observations  on  Abscesses  of  the  Liver  ....  362 

§2.  Observations  on  Cancer  of  the  Liver  ....  372 

§ 3.  Observations  on  Hydatids  of  the  Liver  ....  382 

Section  IY.  Diseases  of  the  Passages  for  the  Excretion  of  Bile  . . 386 


BOOK  III.  Observations  on  Peritonitis  .....  393 

Section  I.  Acute  Peritonitis  .....*.  393 

Chap.  I.  Acute  Peritonitis  terminating  in  Death  ....  393 

Chap.  II.  Acute  Peritonitis  terminating  in  Recovery . . . . 405 

Section  II.  Chronic  Peritonitis  .....  . 407 

Chap.  I.  Chronic  Peritonitis,  Acute  at  the  onset  ....  408 

Chap.  II.  Chronic  Peritonitis,  Chronic  from  the  onset  . . . 410 

Section  III.  Partial  Peritonitis  . . . . . . 411 

Chap.  I.  Epiploitis  .......  412 

Chap.  II.  Partial  Inflammation  of  the  Peritoneum,  Flanks,  &c.  . . 413 

Chap.  HI.  Partial  Inflammation  of  the  Peritoneum  in  the  Pelvis  . . 415 


Chap.  IV.  Partial  Inflammation  of  the  Sub-peritoneal  Cellular  Tissue  . 418 


INTRODUCTION. 


BY  THE  TRANSLATOR. 


The  importance  of  the  study  of  clinical  medicine  is  now  so  universally 
acknowledged,  that  it  appears  altogether  unnecessary  to  occupy  the  reader’s 
time  or  attention  by  pointing  out  to  him  its  various  and  manifold  advantages. 

This  study  may  be  considered  as  the  complement  of  Medical  Education,  it 
being  neither  more  nor  less  than  the  application  of  all  other  branches  of  the 
healing  art  to  that  which  is  their  ultimate  end  and  aim,  namely,  the  prevention, 
alleviation,  and  cure  of  diseases.  In  order  thoroughly  to  understand  a disease, 
it  is  absolutely  necessary  to  have  seen  it,  to  have  carefully  watched  it,  and 
traced  it  through  its  different  stages  during  life,  and  to  note  the  vestiges  which 
it  may  have  left  behind  after  death.  After  this  method  of  studying  disease, 
which  we  hold  to  be  absolutely  indispensable,  accurate  descriptions  of  disease 
coming  from  men  on  whosejudgment,  attainments,  and  experience,  reliance  may 
be  placed,  hold  the  next  rank  : good  descriptions  of  disease  teach  us  the  art  of 
observing  for  ourselves,  they  correct  our  errors,  and  direct  our  attention  to 
objects  which  might  otherwise  have  escaped  us.  These  descriptions,  when 
consulted  after  we  have  devoted  ourselves  for  some  time  to  clinical  observation, 
engrave  the  phenomena  which  we  have  witnessed  more  deeply  in  our  memory. 
Again,  however,  we  would  impress  it  on  the  student’s  mind  — they  never  can  be 
substituted  for  the  actual  observation  of  disease  at  the  bed-side.  In  order  to 
become  sound  physicians,  nature  herself  must  be  interrogated  — that  is  the  book 
which  must  be  attentively  perused. 

For  the  purpose  of  assisting  more  particularly  the  junior  student  in  his  clinical 
studies,  we  shall  offer  a few  observations  principally  in  reference  to  the  import- 
ant subject  of  diagnosis,  the  method  of  examining  a patient,  and  the  more  striking 
phenomena  of  semeiology. 

By  Diagnosis  is  understood  the  knowledge  of  those  characters  which  serve 
to  distinguish  diseases  from  one  another.  The  exact  appreciation  of  the  several 
organic  alterations,  of  the  symptoms,  and  of  the  local  and  general  signs  to  which 
these  alterations  give  rise,  chiefly  constitutes  diagnosis.  This,  whilst  it  is  one 
of  the  most  important  branches  of  pathology,  and  without  doubt  one  of  the  most 
difflcult,  is  also  the  only  basis  on  which  we  can  found  a just  prognosis  and 
rational  treatment. 

•To  assist  in  forming  the  diagnosis,  several  methods  are  occasionally  employed. 
The  first,  and  certainly  the  most  simple,  consists  in  directly  referring  the  symp- 
toms observed  to  the  lesion  of  that  organ  or  tissue  which  those  symptoms  seem 
to  point  out  as  the  seat  of  suffering.  Thus,  when  a patient  presents  himself 
with  difficulty  of  breathing,  cough,  deep-seated  pain,  dulness  of  sound,  and 
crepitous  rale  on  one  side  of  the  chest,  sputa  streaked  with  blood,  etc.,  we  at 
once  pronounce  the  lung  to  be  the  seat  of  the  disease.  If  the  patient  should  die, 
the  post-mortem  examination  confirms  this  part  of  the  diagnosis,  and  completes 
it  by  disclosing  the  nature  of  the  lesion.  If  the  patient  survive,  as  identical 


6 


INTRODUCTION. 


symptoms  cannot  depend  on  different  lesions,  and  post-mortem  examination  has 
shown,  under  similar  circumstances,  that  the  above  mentioned  symptoms  invari- 
ably accompany  such  a lesion  of  the  lung,  the  diagnosis  still  has  all  the  certainty 
that  can  be  desired. 

Another  method  applies  to  cases  in  which  the  symptoms  being  slight  are  not 
easily  interpreted ; when  the  differences  are  not  easily  appreciated  between 
those  which  arise  directly  from  the  organ  affected,  and  those  which  are  merely 
sympathetic  ; this  includes  the  greater  number  of  chronic  diseases.  This 
method  consists  in  interrogating  all  the  organs  one  after  another,  until  we  come 
to  that  which  accounts  sufficiently  for  all  the  symptoms  observed.  Here  we  „ 
commence  by  a rapid  examination  of  the  parts  contained  in  the  head,  chest,  and 
abdomen ; and  in  this  first  review  we  exclude  all  those  organs  and  tissues  of 
whose  healthy  condition  we  entertain  no  doubt,  and  we  note  all  those  which  we 
at  all  suspect  to  be  the  seat  of  any  lesion.  This  first  process  being  concluded, 
we  proceed  to  a second  examination,  which  is  directed  solely  to  the  tissues  or 
organs  suspected.  We  then  make  a new  selection  among  these,  or,  more  pro- 
perly speaking,  we  again  exclude;  this  exclusion  affects  those  whose  suffering 
is  evidently  merely  sympathetic,  still  reserving  those  of  which  we  have  any 
doubt  for  a still  stricter  examination.  Lastly,  in  a third  process  we  remove  suc- 
cessivoely  all  those  tissues,  the  lesion  of  which  does  not  account  sufficiently  for 
all  the  symptoms  observed,  and  thus  we  come  to  the  real  seat  of  the  disease ; 
should  there  be  any  difficulty  then  in  deciding  between  two  organs,  it  is  more 
than  probable  that  there  is  a simultaneous  lesion  of  both. 

In  the  practice  of  medicine  a correct  diagnosis  necessarily  tends  to  a rational 
treatment — in  order  to  form  such  a diagnosis,  it  is  necessary  to  know  the  organs 
and  functions  in  their  normal  state  ; without  this  knowledge  we  cannot  appre- 
ciate the  changes  induced  by  disease.  Anatomy  and  physiology  are,  therefore, 
preliminary  and  indispensable. 

By  the  symptom  of  a disease  is  meant  an  alteration  of  some  parts  of  the 
body,  or  of  some  of  its  functions,  produced  by  a morbific  cause,  and  percepti- 
ble to  the  senses.  From  the  alteration  of  the  function  we  infer  an  alteration  in 
the  organ  to  which  the  discharge  of  such  function  was  confided.  When  we 
have  ascertained  what  organ  is  the  seat  of  lesion,  and  what  the  nature  of  the 
lesion  is,  the  symptom  is  converted  into  a sign.  The  senses  alone  are  suffi- 
cient to  make  us  perceive  the  symptoms ; persons  wholly  unacquainted  with 
medicine  may  ascertain  them.  There  is  no  one,  for  instance,  who  cannot  per- 
ceive what  a pain  of  the  side  is,  with  dyspnoea,  haemoptysis,  &c.  ; it  is  only  the 
physician  who  can  tell  what  these  symptoms  signify ; i.  e.,  can  convert  them 
into  signs. 

The  study  of  mere  symptoms,  without  endeavouring  to  ascertain  the  signifi- 
cation of  these  symptoms,  has  been  at  all  times  productive  of  much  mischief 
in  the  treatment  of  disease.  Not  long  since,  medical  men,  destitute  of  the 
light  of  pathological  anatomy,  considered  mere  groups  of  symptoms  as  diseases, 
against  which  they  directed  their  therapeutic  agents.  This  method,  even  at 
the  present  time,  finds  many  staunch  abettors.  To  illustrate  the  absurdity  of 
this  method,  we  shall  suppose  a case  of  paralysis.  A little  time  ago  it  was  not 
known,  and  several  seem  not  yet  to  know,  that  paralysis  is  but  a symptom^of 
an  alteration  in  the  brain  or  its  appendages.  Pathological  anatomy  has  proved 
this  point  beyond  all  doubt.  Well  ! what  was  the  practice  adopted  in  paralysis  ? 
Frictions  and  rubefacients  were  employed  to  restore  sensation  to  the  paralysed 
limb.  So  far,  if  no  good  was  done,  no  injury  resulted  from  the  practice.  But 
some  one  took  it  in  his  head  to  give  nux  vomica  to  an  animal  ; the  hind  parts 
of  the  animal  were  observed  to  be  convulsed  after  the  employment  of  this  drug  ; 
it  was  thence  inferred  that  the  medicine  would  perform  wonders  in  paraplegia. 

It  was  afterwards  given  in  cases  of  hemiplegia,  and  was  observed  to  produce 


INTRODUCTION. 


7 


convulsions  in  the  paralysed  limbs,  and  forthwith  it  was  expected  that  it  would 
restore  motion  to  these  limbs.  Had  physicians  known  that  paralysis  was  but 
a symptom  of  an  acute  or  chronic  local  affection  of  the  brain,  they  would  have  seen 
that  the  means  proposed  to  give  motion  to  the  paralysed  limbs,  must  necessarily 
act  on  the  diseased  portion  of  the  encephalon  ; and  in  thus  causing  the  diseased 
part  to  act,  they  rather  prevented  than  promoted  its  cure.  They  would  have 
seen,  that  to  make  the  limbs  perform  motion  in  this  case,  was  just  the  same  as 
rubbing  the  two  ends  of  a fractured  bone  one  against  the  other,  by  way  of 
consolidating  the  fracture.  Numerous  other  instances  might  be  adduced  of  the 
absurdity  and  mischief  resulting  from  confining  attention  exclusively  to  the 
symptoms. 

MODE  OF  INTERROGATING  A PATIENT. 

Nothing  is  more  embarrassing  to  a young  and  inexperienced  physician  than 
the  office  of  examining  a patient.  It  is  beyond  all  doubt  one  of  the  most 
important  parts  of  his  profession,  one  without  which  he  cannot  attain  a sure 
diagnosis,  and  consequently  cannot  adopt  a rational  mode  of  treatment.  This, 
is,  however,  a branch  too  much  neglected  in  the  education  of  medical  men. 
There  is  often  great  incoherence  and  confusion  observable  in  their  questions. 
These  questions  are  frequently  totally  mal-apropos,  and  devoid  of  all  connection  ; 
such  persons  oftentimes  confound  objects  the  most  dissimilar,  and  keep  separate 
those  that  bear  the  strongest  resemblances.  These  advantages  arise  from  a 
want  of  order  and  method.  The  mode  of  taking  a case,  as  it  is  closely  con- 
nected with  that  of  examining  a patient,  participates  in  all  the  above  defects  in 
the  hands  of  the  inexperienced. 

The  first  thing  that  should  be  done  is,  to  examine  the  exterior  — the  physio- 
gnomy first  should  engage  our  attention  ; by  this  we  obtain  some  idea  of  the 
patient’s  age  and  strength,  state  of  his  mind,  circumstances  of  prime  importance 
in  establishing  our  prognosis  and  mode  of  treatment.  This  first  examination 
should  not  be  confined  to  the  head  ; the  physician  should  extend  his  examina- 
tion to  all  the  regions  of  the  body,  in  order  that  he  may  be  able  to  judge  of  the 
form  of  the  body,  its  size,  colour,  eruptions,  if  there  should  be  any.  Such  ex- 
amination should  be  made,  where  it  can  be  done  with  convenience.  The 
necessity  of  minutely  examining  the  exterior  of  the  body,  more  particularly  in 
the  part  which  may  be  the  seat  of  pain,  has  been  very  well  pointed  out  by  M. 
Rostan,  in  the  following  case  : — An  aged  woman  was  admitted  into  the  hospi- 
tal under  his  care  : she  complained  of  an  acute  pain  in  the  abdomen,  towards 
the  left  iliac  fossa.  Face  flushed,  skin  hot,  pulse  strong  and  frequent;  tongue 
dry,  considerable  thirst;  digestive  functions  natural,  little  or  no  change  in  the 
other  organic  or  animal  functions.  The  abdominal  pain  was  very  sensible  on 
pressure,  and  when  she  moved.  His  diagnosis  was  as  follows  : the  phenomena 
of  reaction  (strength  and  frequency  of  pulse,  flushed  face,  thirst,  &c.)  indicated 
an  acute  state,  and  one,  no  doubt,  of  an  inflammatory  character.  The  local  sign 
showed,  that  the  abdomen  was  the  seat  of  the  disease  ; but  the  digestive  func- 
tions were  natural,  so  that  it  was  not  in  the  digestive  organs  that  the  inflamma- 
tion was  seated.  The  slightest  pressure  gave  pain,  which  showed  that  the 
disease  was  superficial.  Motion  was  painful*the  organ  of  motion  was  therefore 
affected  ; the  abdominal  muscles  therefore  must  be  the  seat  of  disease.  After 
forming  this  diagnosis,  he  prescribed  for  the  patient  accordingly,  and  then  left 
her,  when  one  of  the  pupils  who  had  raised  the  patient’s  chemise  for  the 
purpose  of  examining  the  seat  of  pain,  followed  him,  and  informed  him  that  it 
was  a case  of  zona.  This  lesion  made  us  feel  more  than  ever,  says  M.  Rostan, 
the  necessity  of  using  our  senses,  the  only  means  of  positive  instruction. 
Another  case  is  mentioned  by  the  same  author  in  proof  of  the  same  theory.  A 


8 


INTRODUCTION. 


patient  had  fallen  on  a pointed  body,  and  felt  considerable  pain  in  the  left  side 
of  the  chest ; there  was  cough,  accompanied  with  great  pain  ; some  expectora- 
tion, sputa  streaked  with  blood,  and  symptoms  of  well-marked  reaction.  The 
pain  was  very  acute  to  the  touch.  One  of  the  pupils  examined  the  patient,  and 
formed  his  diagnosis  thus  : the  cough  and  spitting  of  blood  prove  that  the  re- 
spiratory organs,  and  probably  the  lungs,  must  be  the  seat  of  the  disease. 
The  very  acute  pain  of  the  side,  which  was  increased  both  by  pressure  and  by 
respiration,  might  be,  to  be  sure,  in  the  thoracic  parietes ; but  the  strength  and 
frequency  of  the  pulse,  the  redness  of  the  face,  the  heat  of  skin,  thirst,  &c., 
indicated  a more  deep-seated  lesion,  (percussion  could  not  be  employed  on 
account  of  the  acuteness  of  the  pain  ; a crepitous  rale  was  detected  by  the 
stethoscope).  The  pupil’s  diagnosis  was  pleuro-pneumonia.  This  certainly 
was  reasoning  from  very  correct  principles  ; but  what  was  the  real  state  of  the 
patient  ? There  was  a fracture  of  the  ribs.  Had  the  state  of  the  exterior 
been  examined,  this  error  would  have  been  avoided. 

The  first  question  to  be  addressed  to  a patient  should  be  — “Where  have 
you  any  pain  ?”  This  question,  simple  as  it  may  appear,  is  far  the  best. 
Patients  are  very  much  disposed  to  give  an  opinion  on  the  nature  of  their  own 
case.  One  will  tell  you  that  it  is  his  nerves  that  are  affected  ; another,  that  he 
is  troubled  with  the  bile.  If,  instead  of  putting  the  question  as  is  above  re- 
commended, the  physician  were  to  ask  the  patient  — “What  ails  you  ?”  he 
may  be  sure  to  receive  an  answer  that  will  leave  him  as  much  in  the  dark 
with  respect  to  the  nature  of  the  patient’s  disease  as  he  was  before  he  put  the 
question ; whereas,  by  asking  him  where  his  ailment  lies,  the  patient  seldom 
fails  to  point  out  the  function  and  organ  diseased.  Even  with  this  precision  in 
conducting  our  examination,  it  is  oftentimes  difficult  to  prevent  patients  from 
wandering  into  rigmarole  accounts  concerning  their  complaints ; frequently, 
too,  they  take  one  organ  for  another;  they,  for  instance,  complain  of  a pain  in 
the  stomach,  when  the  seat  of  disease  is  in  the  chest.  It  is  useful,  in  order  to 
avoid  all  misunderstanding,  to  bid  them  lay  their  hand  on  the  part  where  they 
feel  pain.  The  next  question  should  be  < — “ How  long  are  you  ailing  in  this 
way  ?”  By  this  you  ascertain  whether  the  disease  be  acute  or  chronic.  If 
we  discover  that  the  disease  is  of  recent  occurrence,  we  then  confine  our  atten- 
tion solely  to  the  consideration  of  acute  diseases,  excluding  altogether  chronic 
diseases  of  the  same  organ.  We  shall  take  an  example  for  the  sake  of  illustra- 
tion. The  acute  diseases  of  the  brain  are:  — congestion,  inflammation  of  the 
membranes,  that  of  the  cerebral  substance,  hemorrhage,  ramollissement.  The 
chronic  diseases  are:  — tubercles,  cancer,  acephalocysts,  osseous  tumours  of 
the  parietes  of  the  cranium,  fungus  of  the  dura  mater,  general  affections  of  this 
organ,  such  as  hysteria,  epilepsy,  &c.,  &c.  Well,  if  the  disease  is  only  of  a 
few  days’  standing,  we  shall  conclude  that  it  is  acute,  and  shall  lay  aside  all 
those  now  enumerated  in  the  chronic  list;  we  shall  then  confine  our  attention 
to  congestion,  meningitis,  encephalitis,  apoplexy,  &c.,  the  diagnostic  signs  of 
which  we  shall  soon  ascertain. 

Now,  when  we  know  what  the  function  is  that  has  been  injured,  we  must 
follow  up  its  examination,  until  we  have  passed  in  review  all  the  morbid 
phenomena  which  it  may  present.  When  this  examination  is  completed,  we 
pass  on,  to  the  function  or  organ -ivhich  exercises  the  most  marked  influence 
over  that  which  has  been  just  examined,  or  which  receives  the  most  marked 
influence  from  it.  We  then  pass  in  review,  one  after  another,  all  the  principal 
organs  and  their  general  functions.  Whenever  an  organ  is  seriously  affected, 
it  reacts  on  the  other  organs,  disturbs  their  functions,  and  sometimes  their 
structure.  How  are  we  to  discover  these  consecutive  alterations,  unless  by 
examining  all  the  organs  and  all  their  functions  ? 

When  we  have  examined  the  patient  in  the  manner  now  described,  we  next 


INTRODUCTION. 


9 


endeavour  to  ascertain  the  state  of  the  different  organs  contained  in  the  thoracic 
and  abdominal  cavities,  by  means  of  percussion  and  auscultation.  For  a 
description  of  the  mode  of  practising  these  instruments  of  clinical  investigation, 
we  must  refer  to  the  works  expressly  written  on  these  subjects. 

There  are  several  circumstances  which  may  prevent  the  physician  from  ex- 
amining his  patient  in  the  manner  now  described.  He  will  then  be  obliged  to 
have  recourse  to  the  statements  of  those  in  attendance  on  the  patient ; he  must 
make  use  of  his  own  senses  ; the  sense  of  sight  will  make  known  to  him  all  the 
phenomena  regarding  the  external  appearance  of  the  patient ; by  touch  he  can 
discover  the  temperature,  consistence,  and  sensibility  of  most  of  the  superficial 
and  deep-seated  parts,  the  state  of  the  circulation,  &c. ; by  his  ear  he  can  ascer- 
tain all  the  various  sounds  produced  by  percussion,  or  discoverable  by  the 
stethoscope.  We  shall  cite  an  example,  to  show  that  the  difficulty  of  ascer- 
taining the  seat  and  nature  of  a disease,  even  in  cases  wherein  serious  obstacles 
may  present  themselves,  is  not  so  great  as  may  appear  at  first  sight.  Let  us 
suppose  an  example. 

A patient  is  presented  to  us  in  a state  of  complete  loss  of  consciousness.  It 
is  altogether  impossible  to  obtain  from  him  any  information  with  respect  to  his 
present  feelings,  or  the  previous  history  of  the  case.  We  merely  learn  from 
his  friends,  and  those  around  him,  that,  up  to  the  period  of  his  illness,  he  was 
in  the  enjoyment  of  perfect  health,  and  that  the  present  attack  was  sudden. 
Having  no  other  sources  of  information  as  to  the  nature  of  the  case,  we  call  in  our 
senses  and  reason  to  our  aid.  The  former  tell  us  that  the  patient  may  be  about 
sixty  years  of  age  ; that  he  is  of  a strong  make  ; that  the  several  cavities  are  large, 
and  his  limbs  well  developed  ; that  his  face  is  flushed  ; that  the  eyes  are  promi- 
nent, and  that  the  temporal  and  carotid  arteries  beat  with  violence  ; that  he  is 
frothing  at  the  mouth  ; that  the  extremities  are  cold  ; that  one  side  of  the  body 
is  deprived  of  motion  ; that  the  pulse  is  strong  and  hard ; that  he  has  vomited, 
and  that  he  has  passed  his  faeces  involuntarily ; that  the  breathing  is  stertorous. 
What  is  to  be  done  in  this  case  ? Do  we  not  see,  in  a moment,  what  the 
disease  is,  its  nature,  seat,  extent,  and  the  indications  of  treatment  ? Let  us  now 
reason  on  the  case.  There  is  complete  loss  of  consciousness.  What  are  the 
diseases  which  gave  rise  to  this  symptom  ? Diseases  of  the  heart,  of  the  lung, 
and  of  the  brain.  Is  the  heart  the  seat  of  the  disease  at  present  ? No  ; for  the 
patient  was  very  well  before  the  present  attack,  and  the  circulation  was  not  dis- 
turbed. Is  it  syncope  ? No  ; for  the  face  is  flushed,  and  the  pulse  is  strong 
and  full.  Is  it  asphyxia  ? No  ; for  the  respiration  and  circulation  still  exist, 
and  there  was  no  asphyxiating  cause.  The  brain,  therefore,  must  be  the  organ 
involved.  We  have  now  placed  the  disease  in  the  brain,  but  the  diseases  of  this 
organ  are  numerous.  The  disease  evidently  is  notchronic,forthe  patient  was  very 
well  a little  before  the  attack.  Thus,  then,  by  this  single  trait,  we  have  got  rid 
of  one-half  the  cerebral  affections.  W e now  have  left  for  consideration  arachnitis, 
cerebral  congestion,  softening,  and  hemorrhage ; it  cannot  be  congestion,  for 
congestion  is  a general  disease,  and  here  there  are  local  phenomena  : nor  can 
it  be  arachnitis,  for  the  same  reason.  It  must,  therefore,  be  either  softening  or 
effusion  ; but  the  progress  of  softening,  which  also  produces  hemiplegia,  is  slow 
and  gradual,  and  here  the  disease  comes  on  suddenly.  The  case,  therefore, 
must  be  one  of  a cerebral  hemorrhage,  or  apoplexy.  Thus,  then,  have  we  come, 
by  the  mere  application  of  the  senses,  and  by  reasoning,  to  ascertain  the  nature, 
seat,  and  extent  of  the  disease  which  we  have  before  our  eyes,  and  that  with 
almost  mathematical  certainty. 

After  examining  the  patient  in  this  way,  it  next  remains  for  us  to  go  back  to 
the  previous  circumstances  which  might  have  acted  as  causes,  or  which  might 
furnish  some  useful  data  for  the  treatment.  We  should  inquire  to  what  cause 
the  patient  attributes  his  disease  ; whether  the  disease  be  hereditary  or  acquired  ; 


10 


INTRODUCTION. 


whether  the  present  is  the  first  attack  of  it,  or  whether  it  appeared  on  a former 
occasion.  Lastly,  we  should  direct  attention  to  the  age,  sex,  constitution, 
idiosyncrasy,  habits,  and  profession  of  the  patient. 

When  the  disease  terminates  fatally,  the  task  of  the  clinical  observer  is  not 
yet  finished.  This  is  the  moment  when  nature  will  either  confirm  the  accu- 
racy of  his  diagnosis,  or  prove  its  incorrectness.  The  autopsy  requires  the 
same  attention  from  the  physician  as  the  examination  of  the  patient  did  before 
death. 

As  the  same  method  of  examination  may  not  always  apply  in  all  cases,  we 
shall,  for  the  benefit  of  the  junior  student,  annex  the  plan  of  examination  recom- 
mended by  M.  Louis  ; it  is  as  follows  : 

Before  the  clinical  student  inquires  into  the  symptoms  in  any  case,  he  should 
inquire  into  the  age  and  profession  of  the  patient ; into  his  usual  state  of  embon- 
point or  emaciation , of  strength  or  weakness , of  health  or  disease  ; of  the  affec- 
tions under  which  he  laboured  before  the  present ; of  the  natural  conformation 
of  his  body. 

The  reasons  for  these  inquiries  are  obvious. 

When  these  points  are  ascertained,  we  should  next  proceed  to  ascertain  the 
period  when  the  disease  commenced  ; as,  without  knowing  this,  we  could  not 
learn  with  certainty  its  progress  and  duration,  nor  should  we  have  all  the  ele- 
ments of  the  prognosis  and  treatment.  It  should  be  ascertained  whether,  before 
the  time  at  which  the  patient  states  his  disease  commenced,  he  was  in  perfect 
health,  whether  all  the  functions  were  duly  performed  : a strict  inquiry  into 
this  particular  is  indispensable  among  persons  in  the  humbler  walks  of  life, 
since  they  generally  date  the  commencement  of  their  disease  from  the  time  at 
which  they  were  forced  to  give  up  their  ordinary  occupations.  By  way  of 
illustrating  the  necessity  of  this  inquiry,  let  us  suppose  a case  of  pleuritis,  the 
first  symptoms  of  which  commenced  only  a few  days  before  the  patient  came 
under  the  examination  of  the  physician  ; let  us  suppose  that  the  patient  states 
that  he  was  in  perfect  health  before  this  pleuritic  attack  ; here  the  prognosis 
will  of  course  be  favourable,  as  experience  shows  us  that  pleuritis,  attacking  a 
person  previously  in  good  health,  almost  always  terminates  well.  But,  if  we 
ascertain  by  our  inquiries  that  the  patient,  long  before  the  pleuritic  attack,  was 
harassed  with  a cough  ,*  if  wTe  find,  moreover,  that  this  cough  is  connected  with 
tubercles  in  the  lungs,  the  prognosis  and  treatment  will  be  seriously  modified. 

Having  ascertained  the  time  when  the  disease  commenced,  we  then  come  to 
the  consideration  of  the  symptoms.  These  should  be  studied  one  by  one  in 
the  exact  order  in  which  they  appeared  from  the  commencement  of  the  disease 
to  the  period  when  the  patient  comes  on  under  our  examination. 

Pathological  Jdnatomy  should  now  be  brought  in  to  assist  the  other  methods 
of  examination.  The  use  of  pathological  anatomy  is  not  only  to  discover  the 
seat  of  diseases,  to  develop  their  nature,  and  unravel  their  complications  ; by  it 
also  we  arrive  at  a knowledge  of  many  of  the  laws  observed  by  disease,  know- 
ledge which  can  only  be  obtained  from  an  attentive  examination  of  all  the  organs, 
whenever  the  patient  has  died  of  the  disease.  We  now  know,  for  instance, 
that,  after  the  age  of  fifteen,  whenever  we  find  tubercles  in  any  organ,  we  are 
sure  they  also  exist  at  the  same  time  in  the  lungs.  It  is  evidently  to  pathologi- 
cal anatomy  we  are  indebted  for  our  knowledge  of  this  law. 

Having  now  ascertained  the  state  of  the  functions,  and  learned  the  symptoms 
which  have  occurred  from  the  commencement  of  the  disease  up  to  the  period  at 
which  the  patient  came  under  our  inspection,  we  must  next  endeavour  to  ascer- 
tain the  value  of  those  symptoms,  we  must  convert  these  symptoms  into  signs , 
in  order  to  arrive  at  the  knowledge  of  the  organ  affected,  and  of  its  pathological 
state.  This  becomes  the  more  necessary,  as  there  are  cases  in  which  the 
symptoms  do  not,  either  at  the  commencement  of  the  disease,  or  during  a con- 


INTRODUCTION. 


II 


siderable  portion  of  its  progress,  indicate  an  appreciable  alteration  of  any  organ 
whatever.  This  conversion  of  symptoms  into  signs  is  to  be  accomplished  by 
carefully  noting  the  exact  series  and  precise  connection  of  these  symptoms ; 
the  method  of  exclusion,  or  remotion,  also  is  sometimes  to  be  employed  ; that 
is  to  say,  we  attain  a knowledge  of  the  organ  affected,  not  so  much  from  any 
serious  disturbance  of  its  peculiar  functions,  as  because  whilst  the  other  viscera 
gave  no  sign  of  any  appreciable  alteration,  that  viscus  alone  should  be  con- 
sidered as  the  seat  of  the  disease  whose  functions  are  in  any  way  altered,  even 
though  such  alteration  may  not  be  very  marked. 

Having  now  ascertained  the  organ  affected,  our  next  object  is,  to  learn  the 
nature  of  the  disease , of  which  it  is  the  seat.  The  difficulty  of  solving  this 
question  is  not  inconsiderable ; this  difficulty  is  in  a great  measure  occasioned 
by  the  want  of  anatomical  examinations,  carefully  conducted  at  different  periods 
of  the  same  disease.  It  is  chiefly  by  the  aid  of  pathological  anatomy,  by  com- 
paring the  symptoms  with  the  lesions  corresponding  to  them,  that  this  question 
can  be  solved. 

When  we  have  now  ascertained  the  symptoms  of  the  disease,  the  organ  which 
is  its  seat,  the  nature  of  the  disease,  and  its  probable  duration,  the  prognosis 
presents  itself  to  our  consideration.  In  forming  the  prognosis  we  must,  in  addi- 
tion to  the  above  data,  take  into  consideration  the  degree  of  fever  present,  the 
age  and  strength  of  the  patient.* 

* For  much  valuable  information  on  the  subject  of  Clinical  Instruction,  we  refer  the  student 
to  Dr.  Latham’s  “ Lectures  on  Subjects  connected  with  Clinical  Medicine”  (Published  in  the 
Select  Medical  Library ). 


‘ 


> 


( 

' 


• - ' 

. 

. 

: 


DISEASES  OF  THE  ABDOMEN 


FIRST  BOOK. 

DISEASES  OF  THE  DIGESTIVE  TUBE. 

The  changes  found  after  death  in  the  digestive  tube  are  connected  with  two 
great  series  of  changes  of  functions.  In  one  of  these  series,  the  functional  dis- 
turbances are  principally  directed  towards  the  digestive  passages;  there  the 
symptoms  are,  there  also  the  entire  disease  evidently  is.  In  the  other  series  the 
case  is  no  longer  the  same  : the  predominant  functional  disturbances  no  longer 
have  their  site  in  the  digestive  apparatus,  though  in  this  apparatus  the  anatomical 
lesion  still  resides ; and  whilst,  with  respect  to  the  stomach  and  the  intestines,  the 
symptoms  observed  are  but  slightly  marked,  other  organs,  and  principally  those 
of  circulation  and  innervation,  present  disturbances  as  serious  as  they  are  varied, 
in  the  several  acts  which  they  are  commissioned  to  perform.  In  such  a case  we 
cannot  be  led  by  the  mere  symptoms  to  seek  in  the  digestive  passages  for  an 
alteration  to  explain  them.  Thus,  for  a very  considerable  time  the  existence  of 
this  alteration  was  not  even  doubted  ; and  when  it  was  discovered,  many  persons 
still  hesitated  to  admit  that  it  alone  was  the  cause  of  all  the  symptoms,  and  that 
it  alone  constituted  the  entire  disease  ; so  little  proportion  did  there  appear  to 
them  to  be  between  its  intensity  and  the  severity  and  universality  of  the  func- 
tional disturbances.  They  then  gave  to  these  diseases  the  name  of  essential 
fevers.  To  discuss  and  solve,  as  far  as  is  possible  by  the  help  of  facts,  the  im- 
portant questions  which  the  study  of  these  diseases  has  recently  raised,  such  is 
the  object  which  is  to  occupy  us  in  the  following  section.  We  shall  then  have 
to  direct  our  attention  to  diseases  of  the  first  series,  or  those  which  recognise  the 
morbid  state  of  the  digestive  apparatus  for  their  sole  commencement  and  onlyele- 
ment.  The  state  of  these  diseases,  or  at  least  of  some  of  them,  will  be  the 
object  of  a second  section. 


SECTION  I. 

OBSERVATIONS  ON  FEVERS. 

The  diseases  traced  in  the  observations  included  in  this  section  are  those  which 
were  for  a long  time  described  by  the  name  of  essential  fevers,  and  which  are 
designated  in  the  Nosographie  of  Pinel  by  the  terms  inflammatory,  bilious, 
mucous,  adynamic,  and  ataxic  fevers.  It  was  reserved  for  M.  Broussais  to 
change  the  face  of  science  on  this  point,  as  well  as  on  many  others. 

Since  the  publication  of  the  Examen  of  Medical  Doctrines , numerous  works 
have  appeared  in  support  of  the  doctrine  of  the  localisation  of  fevers.  These 
works,  which  all  are  indebted  for  their  appearance  to  those  of  M.  Broussais, 
have  still  further  proved  the  important  part  which  inflammations  of  the  digestive 
2 


14 


ANDRAL’S  MEDICAL  CLINIC. 


tube  perform  in  the  production  of  what  are  called  essential  fevers.  But  they 
have  at  the  same  time  put  some  restrictions  on  the  opinions  expressed  by  M. 
Broussais,  regarding  the  seat  and  nature  of  these  fevers.  Thus  the  valuable 
researches  of  M.  Bretonneau  have  pointed  out,  under  the  name  of  dothinenterite , 
a particular  lesion  of  the  intestinal  follicles  which  coincides  more  frequently  than 
simple  gastro-enteritis  with  the  phenomena  of  what  are  called  essential  fevers. 
It  is  this  same  lesion,  which,  pointed  out  before  M.  Bretonneau’s  time  by  MM. 
Petit  and  Serres  as  the  anatomical  character  of  their  entero-mesenteric  fever, 
had  been  described  by  us  in  the  first  edition  of  the  Clinique  under  the  name  of 
intestinal  exantheme.  We  had  pointed  out  all  the  stages  through  which  the 
patches  ( plaques ) and  isolated  papulae  (boutons)  pass,  from  their  origin  to  their 
transformation  into  ulcers.  M.  Bretonneau  has  added  nothing  either  to  M.  Petit’s 
description,  or  to  ours  ; he  has  merely  assigned  a seat  to  the  exantheme,  by 
placing  it  in  the  follicles.  More  recently,  M.  Louis  has,  by  his  excellent  re- 
marks, put  out  of  all  doubt  the  importance  of  the  exanthematous  lesion  of  the 
intestinal  follicles  in  the  production  of  severe  fevers. 

However,  admitting  that  simple  or  follicular  enteritis  is  the  commencement 
of  a great  number  of  fevers,  can  every  thing  be  explained  by  them  ? We  never 
thought  so  ; and  it  has  always  appeared  to  us  that  these  fevers  never  become 
severe  except  in  consequence  of  a disturbance  which  supervenes  in  the  innerva- 
tion and  hematosis.  This  has  also  been  very  satisfactorily  proved  by  Profes- 
sor Bouillaud,  who  has  contributed  to  give  considerable  weight  to  the  doc- 
trine of  the  localisation  of  fevers,  by  placing  this  doctrine  on  a broader  basis, 
more  particularly  by  establishing  the  reality  of  the  alterations  which  on  the 
one  hand  the  blood,  and  on  the  other  hand  the  nervous  centres  undergo  in 
a great  number  of  fevers.  The  part  performed  by  these  has  also  been  clearly 
demonstrated  by  the  valuable  observations  of  M.  Chaufford,  of  Avignon. 

This  disturbance  of  hematosis  and  innervation  which  gives  rise  to  the  phe- 
nomena called  adynamic  and  ataxic,  or  in  other  words,  to  the  typhoid  state, 
may  be  the  result  of  several  lesions,  different  in  their  nature  and  in  their  seat. 

First,  gastro-intestinal  inflammations  give  rise  to  it  much  more  frequently 
than  diseases  of  any  other  organ.  Of  these  inflammations  some  are  directed 
principally  to  the  intestinal  follicles,  which  become  tumefied,  and  ulcerate; 
others  consist  merely  in  a simple  inflammation  of  the  mucous  membrane  itself. 
Other  organs  also,  however,  though  less  frequently  than  the  digestive  tube, 
may  become  the  occasion  of  that  profound  disturbance  of  innervation  and 
hematosis,  a disturbance  which  constitutes  the  adynamic  and  ataxic  fever  of 
Pinel.  Thus  phlebitis,  pneumonia,  particularly  in  aged  persons,  erysipelas, 
phlegmon,  inflammations  of  the  urinary  passages,  an  abscess  developed  in  the 
prostate,  a matritis,  several  forms  of  inflammation  of  the  liver,  variola,  acute 
inflammation  of  the  synovial  membranes,  etc.,  may  give  rise  to  it.  M.  Boisseau 
has  clearly  proved  this  in  his  physiological  pyretology,  and  it  has  been  put 
out  of  all  doubt  by  several  other  works,  by  those  of  Dance  in  particular. 

But  this  is  not  all,  and  it  may  also  happen  that  instead  of  havingits  commence- 
ment in  a solid,  the  ataxo-adynamic  fever  recognises  for  its  commencement  some 
alteration  of  the  blood,  whether  this  alteration  may  have  taken  place  spontane- 
ously, and  produce  a sort  of  acute  scorbutus,  or  it  may  follow  the  introduction 
of  deleterious  agents,  as  miasms,  virus,  matters  in  a state  of  putrefaction  ; these 
agents,  after  having  modified  the  composition  of  the  blood,  come  to  poison  the 
venous  centres.  Then  the  disease  is  everywhere  where  blood  and  nerves  are  to  be 
found,  and  in  every  part  lesions  may  occur,  which  perform  but  a secondary 
part  in  the  production  of  the  symptoms. 

Thus  the  ataxo-adynamic  or  typhoid  state  may  be  developed  in  consequence 
of  a great  number  of  affections  widely  differing  from  each  other  : it  is  a collec- 
tion of  symptoms,  identical  as  to  their  ultimate  seat,  but  not  as  to  their  origin. 


DISEASES  OF  THE  ABDOMEN. 


15 


Thus  symptoms,  identical  also  as  to  their  nature,  differ  only  in  their  greater  or 
less  intensity  ; with  regard  to  their  progress  and  duration,  they  are  subordinate 
to  the  progress  and  duration  of  the  affection  in  consequence  of  which  the 
typhoid  symptoms  have  been  developed.  If  it  be  a primary  alteration  of  the 
blood  which  gives  rise  to  them,  these  symptoms  may  acquire  in  some  hours 
their  highest  degree  of  development,  and  in  some  hours  even  occasion  death. 
If  the  commencement  be  in  an  organ  where  inflammation  is  rapidly  developed, 
as  in  a lung,  or  in  a vein,  the  typhoid  symptoms  shall  have  a quick  course 
and  a rapid  termination  similar  to  this  inflammation.  If,  on  the  contrary,  they 
are  connected  with  an  inflammation,  which,  as  that  of  the  intestinal  follicles, 
has  stages  which  it  passes  through  with  a certain  degree  of  slowness,  they  will 
be,  like  the  inflammation  itself,  slow  in  their  development,  and  slow  in  their 
termination,  whether  favourably  or  fatally.  This  is,  we  think,  all  the  differ- 
ence between  a typhoid  fever  which  is  connected  with  a phlebitis,  for  instance, 
and  that  which  follows  a dothinenterite.  There  will  be,  however,  in  each  of 
them,  some  particular  symptoms,  which  will  depend  on  the  local  lesion,  as 
the  diarrhoea  in  the  case  of  follicular  enteritis.  We  may,  no  doubt,  as  M. 
Louis  has  done,  reserve  the  term  typhoid  fever  for  the  morbid  state  which  pro- 
ceeds along  with  the  affection  of  Peyer’s  glands  ; this,  however,  is  a distinc- 
tion purely  arbitrary  ; and  besides,  this  mode  of  proceeding  seems  to  us  to  be 
attended  with  the  inconvenience  of  thus  designating  a great  number  of  cases 
of  follicular  enteritis,  in  which  the  term  typhoid  affection  has  no  longer  any 
meaning  ; for  all  cases  of  follicular  enteritis  are  certainly  not  accompanied 
either  with  stupor  or  the  different  phenomena  of  ataxic  or  adynamic  fever  ; 
all  do  not  resemble  typhus  ; they  are  oftentimes  mere  inflammatory,  bilious, 
or  mucous  fevers,  to  use  for  a moment  the  language  of  the  Nosographie  Philo - 
sophique. 

We  do  not  then  think  it  right  to  retain  the  term  typhoid  fever,  because  this 
term  leaves  a vagueness  in  the  mind,  which  is  not  in  science,  and  because  it 
often  fails  in  exactness  with  respect  to  the  symptoms  which  it  represents.  We 
admit  as  a possible  but  never  necessary  consequence  a typhoid  state  in  a great 
number  of  diseases,  that  is  to  say,  a state  in  which  there  appear  some  general 
symptoms  more  or  less  similar  to  those  which  characterise  typhus.  This  state 
indicates  that  the  disease  no  longer  entirely  exists  in  the  organ  where  it  had 
commenced  ; it  is  in  some  degree  the  signal  that  the  blood  and  nervous  centres 
participate  in  the  disease.  Thenceforward  the  nature  of  this  disease  is  no 
longer  the  same,  and  other  therapeutic  indications  present  themselves  to  be 
fulfilled. 

We  hope  that  the  observations  which  are  now  about  to  be  made  will  contri- 
bute to  throw  some  light  on  the  questions  just  started. 


CHAPTER  I. 

CONTINUED  FEVERS  TERMINATING  IN  DEATH. 

In  classing  the  cases  relating  to  those  diseases  according  to  the  seat  of  the 
lesions  which  they  leave  after  them,  we  are  led  to  distribute  them,  according 
to  our  observation,  into  three  principal  articles. 

In  the  first  are  arranged  the  cases,  where  we  ascertained  in  the  digestive  tube 
the  existence  of  the  lesion  described  by  us  in  the  former  edition  of  this  work 
under  the  name  of  intestinal.exantheme,  and  by  M.  Bretonneau  under  the  name 
of  dothinenterite.  These  cases  are  the  most  numerous.  They  constitute  the 
typhoid  fever  of  M.  Louis.  The  disease  with  which  they  are  connected  seems 
to  us  more  suitably  designated  by  the  terms  exanthematous  or  follicular  entente. 


1 G 


ANDRAL’S  MEDICAL  CLINIC. 


or  even  by  that  of  dothinenterite.  Should  there  be  any  repugnance  to  the  ad- 
mission of  these  terms,  as  appearing  to  prejudge  a question  which  is  in  dis- 
pute, we  would  still  prefer  to  the  term  typhoid  fever,  that  of  entero-mesenteric 
fever,  which  had  been  employed  by  MM.  Petit  and  Serres.  At  the  same  time 
that  it  does  not  place  the  intestinal  lesion  in  the  first  rank,  it  has  at  least  the 
advantage  of  marking  it ; it  attaches  the  mind  to  something  precise,  by  refer- 
ring it  to  the  anatomical  character  of  the  disease. 

Under  the  second  article  we  give  the  cases,  fewer  in  number,  in  which  the 
digestive  tube  no  longer  presented  to  us  an  affection  of  its  follicles,  but  a sim- 
ple inflammation  of  its  mucous  membrane,  characterised  by  the  redness  and 
softening  of  this  membrane.  This  is  the  gastro-enterite,  first  described  by  M. 
Broussais.  We  shall  prove  that  it  may,  as  well  as  the  follicular  enteritis,  give 
rise  to  typhoid  symptoms,  but  in  a smaller  number  of  cases.  The  febrile 
disturbance  which  it  excites,  has  also,  in  general,  a shorter  duration  and  less 
determinate  periods  than  that  to  which  follicular  enteritis  gives  rise ; perhaps, 
also,  we  may  master  it  more  easily  and  arrest  it  with  more  certainty  in  its  pro- 
gress than  the  fever  connected  with  a dothinentery. 

Lastly,  in  a third  article,  we  shall  detail  the  eases  in  which,  whilst  ataxo- 
adynamic  or  typhoid  symptoms  were  still  observed,  we  no  longer  discovered  any 
lesion  in  the  digestive  tube.  But,  elsewhere,  in  different  organs,  alterations 
are  found  which  may  be  regarded  as  the  origin  of  these  symptoms.  But  these 
alterations  do  not,  any  more  than  those  of  the  digestive  tube,  constitute  the 
entire  disease  ; they  are  in  some  degree  but  the  occasion  of  its  development, 
nearly  as  a wound  which,  in  certain  predispositions  of  the  system,  becomes 
an  occasional  cause  of  tetanus.  Here,  as  in  cases  of  simple  or  follicular  enteritis, 
it  is  in  the  nervous  centres  secondarily  affected,  that  we  must  seek  the  cause 
of  the  severity  of  the  disease  ; it  is  in  the  nature  of  the  modifications  which 
the  nervous  centres  have  undergone,  that  we  must  seek  the  explanation  of  the 
symptoms  ; it  is  to  the  state  of  those  centres  that  the  treatment  must  in  a great 
measure  be  made  subordinate. 


ARTICLE  I. 

CONTINUED  FEVERS,  CONNECTED  WITH  FOLLICULAR  INFLAMMATION  OF 

THE  INTESTINES. 

In  the  following  cases  we  shall  endeavour  to  trace  the  follicular  enteritis 
through  its  different  stages,  from  that  where  it  constitutes  only  some  elevations 
scattered  over  the  inner  surface  of  the  small  intestines,  to  that  where  the  ulcer- 
ations which  have  succeeded  those  elevations  are  themselves  cicatrised.  We 
shall  study  what  are  the  symptoms  which  have  accompanied  the  different 
phases  of  this  kind  of  exantheme  ; we  shall  strive  to  determine  their  relations 
to  the  latter;  and,  finally,  we  shall  see  how  far  the  disease,  in  its  different 
symptomatic  forms,  is  influenced  either  favourably,  or  unfavourably,  by  the 
different  therapeutic  methods. 


SECTION  I. 

CASES  OF  FOLLICULAR  ENTERITIS  AT  THE  PERIOD  OF  THE  EXANTHEME. 

Case  1.  — Symptoms  of  bilious  fever;  no  diarrhoea  — Death  from  pneumonia  nine  days  after 
the  termination  of  the  primary  disease  — Tumefaction  of  the  follicles  of  the  small  intestine. 

A man,  twenty-seven  years  of  age,  residing  in  Paris  for  the  last  thirteen 
months,  experienced  for  some  time  back  a loss  of  appetite,  some  headach,  a 


DISEASES  OF  THE  ABDOMEN. 


17 


sensation  of  unusual  debility.  One  evening,  after  supper,  he  had  a shiver- 
ing; all  that  night  he  felt  a burning  heat.  On  the  next  day  this  heat  con- 
tinued ; he  had  a slight  pain  in  the  throat,  and  vomited  the  food  which  he 
took  the  day  before.  The  evening  after  that  he  entered  the  Charite.  Examined 
the  next  day,  the  third  day  of  his  illness,  he  presented  the  following  state  : — 
Countenance  yellow,  with  redness  of  the  cheeks  ; supra-orbital  headach  ; 
eyes  injected  ; general  debility  ; motion  painful ; pains  in  the  joints.  Lips  dry  ; 
tongue  covered  with  a thick  yellow  coat,  of  a bright  red  at  the  edges  and  apex  ; 
bitter  taste  in  the  mouth,  not  much  thirst;  deglutition  slightly  painful  ; abdo- 
men soft,  and  free  from  pain  in  every  part ; no  stools  since  the  commence- 
ment of  the  disease.  A little  cough  ; mucous  rale  in  some  points.  Pulse 
frequent  and  hard;  skin  dry,  and  of  an  acrid  heat.  (Venesection  to  twelve 
ounces;  ptisan  of  barley,  lavement  (enema),  diet.) 

On  the  following  day,  the  fourth  day,  state  of  patient  not  changed.  (A 
second  venesection.)  Delirium  in  the  night  of  the  fourth  daj^. 

On  the  fifth  and  sixth  days,  the  yellow  tint  of  the  face  becomes  more  and  more 
marked  ; features  sunk  ; the  patient  looks  with  an  air  of  amazement  at  those 
around  him  ; his  answers  are  slow  ; coating  of  the  tongue  very  thick  ; abdomen 
not  tense  ; constipation  still  continues.  On  the  morning  of  the  sixth  day,  we 
were  struck  with  the  way  in  which  the  respiration  was  performed  ; it  was  high 
and  accelerated  : on  examining  the  chest,  we  discover  a well-marked  crepitous 
rale  all  over  the  lower  lobe  of  the  left  lung ; in  this  same  extent  there  was  a 
slight  diminution  of  sonorousness  of  the  thoracic  parietes  ; no  expectoration  ; 
pulse  extremely  frequent.  Existence  of  pneumonia  evident.  (Venesection  to 
twelve  ounces,  sinapisms  to  the  lower  extremities.)  Neither  the  blood  drawn 
on  this  nor  on  the  preceding  occasion  was  buffed.  In  the  night,  the  patient 
became  delirious. 

On  the  morning  of  the  seventh  day,  dyspnoea  very  great;  expectoration  not 
more  than  on  the  preceding  day.  On  the  posterior  and  lateral  part  of  the  chest 
on  the  left  side  the  sound  was  dull,  and  neither  crepitous  rale  nor  respiratory 
murmur  was  heard  there.  The  state  of  the  digestive  passages  was  the  same. 
Answers  were  obtained  with  difficulty  from  the  patient.  (Two  blisters  to  the 
legs.)  Delirium  in  the  night. 

On  the  eighth  day  the  same  state.  On  the  ninth  extreme  dyspnoea;  the 
patient  can  with  difficulty  pronounce  some  words  in  broken  accents.  He  died 
in  the  course  of  the  day. 

Post-mortem.  The  brain  and  its  appendages  considerably  injected,  a cir- 
cumstance which  seems  connected  with  the  state  of  asphyxia  in  which  the 
patient  died. 

The  lower  lobe  of  the  left  lung  was  completely  hepatised ; the  remainder  of 
the  pulmonary  parenchyma,  on  the  left  and  right  sides,  very  much  engorged. 
The  heart  contained,  on  the  right  side,  a large  black  clot  of  but  little  con- 
sistence. 

The  inner  surface  of  the  stomach  presented  nothing  but  a certain  number  of 
submucous  veins  gorged  with  blood,  which  were  particularly  apparent  towards 
the  great  cul-de-sac.  The  mucous  membrane  itself  was  every  where  pale,  and 
of  the  ordinary  consistence. 

This  same  venous  injection  in  the  three  lower  fifths  of  the  same  intestine. 
At  the  extent  of  two  feet  above  the  ileo-caecal  valve,  there  existed  five  large 
patches  of  a reddish-grey  colour,  of  an  oval  form,  occupying  the  free  edge  of 
the  intestine,  forming  a slight  prominence  above  ihe  level  of  the  rest  of  the 
mucous  membrane.  These  patches  evidently  resulted  from  hyperemic  tume- 
faction of  the  follicles  of  the  intestine;  between  these  patches  some  small  pus-» 
tules  were  found,  some  red,  others  of  a whitish-grey  colour,  which  are  nothing 
but  isolated  follicles.  Between  these  pustules,  or  between  the  patches,  tltQ 


18 


ANDRAL’S  MEDICAL  CLINIC. 


mucous  membrane  was  pale.  The  inner  surface  of  the  large  intestine  was  white 
through  its  entire  extent. 

This  case  furnishes  a well-marked  instance  of  dothinenterite  in  its  first  stage. 
At  the  time  the  patient  entered  the  hospital,  the  respiratory  apparatus  presented 
nothing  but  slight  irritation  of  the  bronchi,  and  it  was  not  there  we  were  to 
seek  the  cause  of  the  fever.  Was  there  any  other  organ  in  a state  of  suffering  ? 
In  no  part,  except  at  the  pharnyx,  was  there  any  pain  discovered  ; the  abdo- 
men retained  its  natural  softness,  and  freedom  from  pain.  There  was  no  diar- 
rhoea, but  there  was  merely  observed  a saburral  state  of  the  tongue,  with  red- 
ness of  its  periphery,  which  coincided  with  a bilious  tint  of  the  face.  Add  to 
this  the  state  of  the  skin,  and  of  the  pulse,  and  we  shall  have  the  disease  de- 
scribed by  nosographers  under  the  title  of  bilious  f aver.  Still  what  informa- 
tion did  we  obtain  from  the  post-mortem  ? It  revealed  to  us  a morbid  state  of 
the  intestinal  follicles;  and  as  this  same  state  has  been  found  in  cases  where, 
a long  time  before  death,  the  same  symptoms  has  been  observed  during  life, 
we  are  warranted  in  supposing  that  there  is  a remarkable  connexion  between 
these  symptoms  and  the  intestinal  disease  ; we  may  say  that  it  is  the  latter 
which  was  at  least  the  commencement  of  the  former.  This  disease  is  still  in 
its  first  stage  ; it  as  yet  consists  but  in  a species  of  exantheme.  Now  one 
may  be  asked  at  what  precise  period  did  the  exantheme  commence  ; was  it 
only  the  day  the  shivering  manifested  itself,  and  from  whence  we  dated  the 
commencement  of  the  disease?  But  then  we  shall  ask,  what  was  the  lesion 
which,  previous  to  this  day,  had  produced  anorexia,  headache,  and  general 
illness  ? If  the  intestinal  lesion  commenced  simultaneously  with  the  first  de- 
rangement of  health,  was  it  by  becoming  all  at  once  more  intense,  or  by  changing 
its  nature,  that  it  produced  the  fever  ? 

Be  that  as  it  may,  we  should  remember  from  this  case  that  a dothinenterite 
may  develope  itself  without  producing  either  pain,  tension  of  the  abdomen,  or 
diarrhoea.  Neither  should  we  forget  the  state  of  the  tongue,  which  was  not 
explained  in  this  case  by  any  morbid  state  of  the  stomach.  In  this  latter  organ 
there  was  not  more  saburra  than  irritation,  and  its  examination  after  death 
would  no  more  have  justified  the  administration  of  an  emetic  than  the  applica- 
tion of  leeches  to  the  epigastrium. 

If  we  now  study  this  disease  with  respect  to  its  progress,  and  with  respect 
to  the  therapeutic  means  opposed  to  it,  we  shall  find  that  here,  as  in  many 
other  cases,  bloodletting  exercised  no  beneficial  influence  : every  day,  in  spite 
of  it,  we  perceived  the  disease  to  become  worse  ; the  delirium,  which  returned 
every  night,  the  appearance  of  the  countenance,  the  disturbance  of  the  intellect 
and  of  speech,  the  continually  increasing  difficulty  of  moving  were  such  as 
should  cause  one  to  dread  the  transformation  of  the  disease  into  adynamic  fever , 
properly  so  called,  when  the  pneumonia  which  prematurely  terminated  the 
patient’s  life,  declared  itself.  This  pneumonia  was  remarkable  for  the  rapidity 
with  which  it  passed  from  the  first  to  the  second  stage  ; no  pleuritic  pain  ac- 
companied it;  no  characteristic  expectoration  marked  its  existence.  Here  is 
a case,  among  a thousand  others,  in  which  the  previous  bloodletting  did  not 
prevent  a new  inflammation  from  setting  in. 

Case  2. — Symptoms  of  ataxic  fever  — Death  six  days  after  the  invasion  — Tumefaction 
of  the  intestinal  follicles — No  appreciable  lesion  in  the  nervous  centres. 

A servant,  thirty-one  years  of  age,  entered  the  hospital  in  a state  of  com- 
plete delirium.  1’hose  who  brought  him  staled  that  four  days  previously  he 
had  been  seized  with  headach  and  fever.  Only  on  the  day  before  his  admis- 
sion, he  commenced  to  rave.  When  wc  saw  him,  his  face  was  very  much 
flushed  ; the  eyes  rolled  continually  in  the  orbits,  as  if  agitated  with  convul- 
sive movements.  The  patient  uttered  some  words  uneonnectedly,  and  no 


DISEASES  OF  THE  ABDOMEN. 


19 


answer  could  be  obtained  from  him  ; the  strait-waistcoat  had  to  be  put  on  him. 
The  trunk  was  in  constant  motion  ; tongue  red  and  dry  ; profuse  salivation 
set  in  ; abdomen  soft;  no  diarrhoea.  The  pulse  more  than  120  ; still  retained 
considerable  strength.  (Venesection  to  twelve  ounces  ; thirty  leeches  to  the 
neck.) 

On  the  two  days  following,  the  delirium  continued  without  any  lucid  inter- 
val : the  tongue  became  more  and  more  dry  ; face  pale  ; pulse  extremely  fre- 
quent, and  thready,  and  the  patient  died  towards  the  end  of  the  sixth  day. 
The  constipation  did  not  cease  ; the  abdomen  became  a little  tympanitic  on 
the  second  day.  — Thirty  more  leeches  were  applied  to  the  neck  on  the  fifth 
day,  and  on  the  sixth  two  blisters  were  applied  to  the  legs,  which  did  not  take. 

Post-mortem.  Meninges  pale  ; no  encephalic  injection.  Thoracic  organs 
healthy.  Two  red  patches,  each  the  size  of  a two  franc  piece,  were  observed 
towards  the  great  cul-de-sac  of  the  stomach.  These  patches  consisted  of  a 
dotted  injection  of  the  mucous  membrane  ; in  every  other  part  this  membrane 
was  of  a good  consistency. 

Small  intestine  white,  without  any  appreciable  lesion,  in  its  upper  five- 
sixths.  The  lower  fifth  presented,  1st,  some  oval  red  patches,  evidently  con- 
sisting of  diseased  follicles  ; 2dly,  a great  number  of  small  conical  pustules, 
equally  red,  which  seemed  to  us  nothing  but  isolated  follicles.  Between 
them  the  mucous  membrane  was  white,  and  of  a good  consistence,  A few 
similar  pustules  existed  in  the  caecum.  The  rest  of  the  large  intestine  was 
pale,  its  mucous  membrane  not  softened. 

The  alterations  of  the  digestive  tube,  found  in  the  body  of  this  patient,  are 
the  same  as  those  which  we  saw  in  the  preceding  case.  Here  there  were 
but  the  two  small  red  spots  of  the  stomach.  Yet  what  a difference  in  the 
symptoms  ! The  subject  of  this  case  appeared  one  who  should  have  pre- 
sented after  death  lesions  connected  with  the  brain,  and  none  were  discovered. 
The  encephalon  and  its  appendages  were  even  found  paler  than  in  the  subject 
of  the  first  case,  where  delirium  existed  only  at  intervals.  In  other  respects 
there  was  in  both  the  same  absence  of  local  symptoms  with  respect  to  the 
abdomen  ; the  tongue,  however,  in  both  cases,  lost  its  natural  appearance. 
But  it  was  in  the  second  that  it  was  modified  in  the  most  serious  manner. 
Is  it  the  two  small  red  spots  found  in  the  stomach  that  shall  explain  in  this 
case  the  redness  and  dryness  of  the  tongue  ? But  in  how  many  persons  do 
we  not  find  more  intense  and  more  extensive  injection  in  the  mucous  mem- 
brane of  the  stomach,  without  the  tongue  having  been  altered  during  life ! 

Here  then  are  two  individuals  in  whom  one  and  the  same  lesion  of  the  in- 
testine is  not  revealed  by  any  other  local  symptom  than  by  a modification  of 
the  state  of  the  tongue,  which  in  both  is  not  the  same ; still  further,  this  intes- 
tinal lesion,  identical  in  both,  is  accompanied  in  both  by  general  symptoms  of 
a very  different  description. 

Again,  the  intestine  examined  here  on  the  sixth  day,  presented  the  same 
alteration  as  in  the  preceding  case,  where  it  was  only  on  the  ninth  day  it  was 
examined. 

Here  again,  as  in  the  first  case,  we  can  perceive  the  total  inefficacy  of  blood- 
letting, both  general  and  local.  By  this  I do  not  mean  to  say  that  we  must 
not  have  recourse  to  it;  I only  say  that  by  it  we  do  not  always  master  the 
disease,  nor  do  we  always  arrest  it  in  its  progress.  These  cases,  moreover, 
are  not  the  only  ones  of  this  kind  which  I might  adduce.  Out  of  the  hospi- 
tals I might  cite  several  instances  of  young  medical  students,  who,  being  bled 
very  largely  from  the  very  commencement,  and  during  the  course  of  diseases 
similar  in  their  nature  to  that  just  now  cited,  still  were  carried  off.  I shall 
here  quote  only  the  two  following  cases,  as  instances  of  the  frequent  inefficacy 
of  bloodletting,  whatever  be  the  period  of  the  disease  at  which  it  is  employed. 


20 


ANDRAL’S  MEDICAL  CLINIC. 


A medical  student,  twenty-two  years  of  age,  who  had  been  residing  in  Paris 
for  about  three  months,  in  a spacious  and  airy  bedchamber,  had  worked  very 
assiduously,  had  lived  very  well,  and  had  not  committed  any  excess  since 
his  arrival  in  Paris.  Toward  the  end  of  January,  1829,  he  was  seized  with 
a violent  headach,  which  he  tried  to  remove  by  a purgative.  The  headach, 
far  from  lessening  after  this,  increased  and  continued  for  three  days,  without 
any  other  symptom  : then  some  fever  appeared,  and,  at  the  same  time,  the  in- 
tellect became  disturbed.  He  was  bled  twice  from  the  arm  without  any 
amendment  following.  The  intellects  became  even  more  and  more  disturbed  ; 
pulse  very  frequent.  Thirty  leeches  were  applied  to  the  neck,  and  a consi- 
derable quantity  of  blood  flowed  from  their  bites.  The  day  after  their  appli- 
cation the  face  was  pale  ; features  remarkably  sunk  ; the  delirium  continued 
worse  than  ever;  subsultus  tendinum  very  frequent,  and  the  tongue  which, 
till  then,  was  only  white,  was  now  dry.  Ice  was  then  applied  to  the  head  ; 
all  the  symptoms  became  worse  ; continual  tremor  of  the  muscles,  in  which 
the  tongue  participated,  when  the  patient  attempted  to  protrude  it  from  the 
mouth  ; pulse  became  thready,  and  the  patient  died. 

In  another  medical  student  of  the  same  age,  and  living  about  the  same  length 
of  time  in  Paris,  not  addicted  to  any  species  of  irregular  conduct,  the  first  de- 
rangement of  health  manifested  itself,  as  in  the  preceding  case,  by  an  intense 
headach,  which,  after  having  continued  for  three  days,  was  accompanied  with 
fever.  A first  bleeding , employed  on  the  same  day  that  the  fever  appeared, 
was  not  followed  by  any  improvement.  The  next  day  a second  bleeding  ; 
headach  still  continued  ; pulse  became  more  frequent,  tongue  white  and  moist. 
Leeches  were  applied  to  the  anus  ; no  amendment;  he  was  bled  from  the  foot ; 
the  headach  continued  as  well  as  the  fever.  Recourse  was  then  had  to  cold 
applications  to  the  forehead.  The  temples  were  rubbed  with  ether;  sina- 
pisms were  applied  to  the  legs.  The  headach  disappeared,  and  the  patient 
appeared  better.  But  the  next  day  the  frequency  of  the  pulse  again  increased, 
and  slight  disturbance  of  the  intellect  was  observed.  On  the  following  day, 
all  the  symptoms  of  violent  fever  declared  themselves;  repeated  epistaxis, 
dryness  and  blackness  of  the  tongue,  leaden  tint  of  the  face  ; subsultus  tendi- 
num ; irregularity  of  muscular  action  ; tympanitic  state  of  the  abdomen,  dis- 
turbance of  the  intellect,  at  first  intermittent,  then  continued.  Pulse  very 
frequent  and  small  ; death. 

Here  are  two  more  well-marked  cases,  where  bloodletting  was  equally  in- 
effectual, either  to  remove  the  still  slight  symptoms  which  existed  at  the  time 
it  was  employed,  or  to  prevent  the  development  of  more  alarming  symptoms. 

Case  3.  — Symptoms  of  ataxo-adynamic  fever  — Death  on  the  eleventh  day  — Tumefaction 

of  the  follicles  of  the  ileum  and  caecum  — Injection  of  the  meninges  and  of  the  exterior 

grey  substance  of  the  cerebral  hemispheres  — Spleen  large  and  soft. 

A peruke-maker,  eighteen  years  of  age,  exhausted  by  excess  in  venery  and 
that  of  the  table,  felt,  on  the  3d  September,  towards  two  o’clock  in  the  after- 
noon, and  without  any  known  cause,  a violent  shivering,  which  lasted  for 
three  hours  ; this  was  succeeded  by  heat,  then  a profuse  sweat  set  in,  and 
continued  till  the  following  morning.  The  four  following  days,  there  was 
constant  heat,  perspiration  at  night,  headach  ; mouth  very  foul,  anorexia,  diar- 
rhoea. During  all  this  time  the  patient  kept  his  bed,  and  drank  nothing  but 
eau  sucree.  He  entered  the  Charite  on  the  7th  of  September;  he  walked  to 
the  hospital ; in  the  course  of  that  night  he  raved  a little. 

On  the  8th  headach  less,  countenance  red,  eyes  brilliant;  tongue  dry, 
scarcely  red  ; thirst,  anorexia,  mouth  very  foul;  abdomen  a little  tympanitic, 
slightly  painful  on  pressure  ; stools  watery,  preceded  by  colicky  pains  ; pulse 
frequent,  a little  hard ; skin  hot. 


DISEASES  OF  THE  ABDOMEN. 


21 


On  the  nightof  the  8th,  the  patient  again  became  delirious  ; on  the  morning 
of  the  9th,  the  delirium  continued  ; the  eyes  remained  closed  ; face  very  red  ; 
the  pulse,  moderately  frequent,  had  lost  it  hardness.  (Bleeding  to  two  palettes  ; 
sinapisms  to  the  knees.) 

On  the  10th,  some  amendment;  intellects  clearer;  but  from  time  to  time, 
however,  his  ideas  again  became  disturbed  ; the  tongue  was  always  a little  dry, 
the  abdomen  tympanitic  ; two  liquid  stools.  (Twelve  leeches  to  the  anus, 
sinapisms  to  the  legs  in  the  evening.) 

The  delirium  returned  in  the  day  ; at  night  we  were  obliged  to  tie  him,  in 
order  to  prevent  him  from  escaping  from  his  bed. 

On  the  11th,  he  was  sunk  in  a profound  stupor,  from  which,  however,  it 
was  not  difficult  to  arouse  him  ; he  answered  questions,  but  knew  not  where 
he  was  ; he  pronounced  some  unconnected  words,  and  then  his  eyes  closed 
again  ; the  pulse,  which  was  weak,  had  become  very  frequent;  digestive  func- 
tions in  the  same  state.  (Eight  leeches  to  the  anus  ; two  blisters  to  the  legs 
in  the  evening  ; barley  water  with  gum.) 

On  the  12th,  state  of  coma  more  marked  ; four  involuntary  stools.  (Four 
leeches  behind  each  ear;  embrocations  of  camphorated  oil  of  camomile  to 
the  abdomen ; aromatic  frictions  to  the  extremities  ; two  more  blisters  to  the 
thighs.) 

The  leeches  prescribed  for  the  neck  were  applied  to  the  anus  ; in  the  dayihe 
patient  emerged  from  the  state  of  coma  ; became  very  uneasy,  wept  and  cried 
aloud.  (The  same  prescription,  except  the  blisters.) 

On  the  13th,  we  scarcely  approached  his  bed,  when  he  began  to  cry,  and 
appeared  sunk  in  despair  ; he  no  longer  returned  any  answers  ; however,  he  still 
retained  sufficient  intellect  to. show  his  tongue  when  signs  were  made  to  him 
to  do  so.  The  tongue  was  dry,  a little  brown  at  its  centre ; he  had  had  no 
stool.  (Mineral  lemonade.) 

On  the  14th,  profound  coma  ; conjunctiva  injected  ; face  covered  with  a cold 
clammy  sweat;  extremities  icy  cold  ; pulse  thready,  and  so  frequent  that  it 
could  not  be  counted  ; death  two  hours  after  the  visit  (from  the  10th  to  the 
11  th  day  of  the  disease. 

Post-mortem  twenty-two  hours  after  death.  Cranium.  — The  arachnoid  of 
the  convexity  of  the  hemispheres  considerably  injected.  It  was  torn  with  the 
greatest  ease  ; on  endeavouring  to  raise  it,  we  detached  with  it  some  superficial 
portions  of  the  cerebral  convolutions.  The  surface  also  of  the  hemispheres  pre- 
sented a slight  rosy  lint.  The  ventricles  contained  but  a very  small  quantity 
of  serum.  Arachnoid  of  the  base  not  injected. 

Thorax. — Both  lungs  engorged  w i th  a great  quantity  of  bloody  serum.  The 
heart  contained  some  black  blood  half  clotted. 

Abdomen.  — The  inner  surface  of  the  stomach  was  pale  through  all  its  ex- 
tent. The  duodenum  was  white,  as  also  the  jejunum  in  its  upper  three-fourths. 
The  lower  fourth  presented  several  red  patches,  which,  altogether,  might  fill 
up  about  from  eight  to  ten  inches  in  length.  The  whiteness  re-appeared  in 
tire  upper  two-thirds  of  the  ileum.  In  its  lower  third,  numerous  elevations 
were  seen  to  arise  from  its  inner  surface,  projecting  one  or  two  lines  above  the 
mucous  membrane  ; their  breadth  varied  from  that  of  a grain  of  hemp-seed  to 
that  of  a large  lentil ; the  colour  was  a dull  white.  In  the  centre  of  three 
or  four  of  them  there  was  a slight  loss  of  substance,  hardly  equalling  the  size 
of  a pin’s  head.  They  were  all  seated  in  the  mucous  membrane.  At  first 
distinct,  they  became  confluent  near  the  ileo-caecal  valve  ; where  they  were 
distinct,  the  mucous  membrane  placed  in  the  intervals  between  them  retained 
its  white  colour;  lower  down  this  membrane  had  acquired  a rosy  tint. 

In  the  caecum  and  in  the  transverse  and  ascending  colons  these  elevations 
were  again  found,  but  much  fewer  in  number.  Scarcely  four  or  five  of  them 


22 


ANDRAL’S  MEDICAL  CLINIC. 


were  counted  in  a space  of  six  inches  in  length.  However,  the  mucous  mem- 
brane was  more  injected  than  that  of  the  extremity  of  the  small  intestine. 

The  remainder  of  the  colon  and  the  rectum  were  white  and  healthy. 

The  spleen  was  extremely  large  ; its  tissue  was  dense  and  black. 

The  biliary  ducts  and  gall-bladder  contained  a liquid  of  a dirty  grey  colour 
entirely  different  from  bile. 

This  disease  again  presents  an  aspect  different  from  that  of  the  preceding. 
Some  well-marked  symptoms  of  intestinal  irritation  marked  its  commencement : 
there  was  no  longer  here  constipation  as  in  the  preceding  cases ; diarrhoea  ex- 
isted from  the  very  beginning;  it  was  ushered  in  by  a shivering,  and  appeared 
simultaneously  with  the  fever.  The  sweat  which,  at  first,  appeared  every  night, 
is  a phenomenon  of  rather  rare  occurrence  in  cases  of  this  kind.  However, 
more  alarming  symptoms  soon  supervened.  The  intellects  were  at  first  dis- 
turbed at  intervals,  then  the  disturbance  became  continued;  remarkable  alter- 
nations of  extreme  agitation  and  profound  coma  were  observed  ; the  abdomen 
became  tympanitic,  and  the  tongne  dry  and  brown.  On  opening  the  body  the 
same  exanthematous  patches  were  found  in  the  small  intestine;  ulceration 
seemed  to  be  commencing  in  some  of  them  ; some  of  a considerable  size  were 
also  found  in  the  caecum,  and  this  latter  circumstance  explains  the  diarrhoea 
which  existed  at  the  onset  of  the  disease.  Still  further,  there  was  here  in 
several  points  of  the  intestine  a redness  of  the  mucous  membrane  itself,  which 
was  wanting  in  the  two  preceding  cases.  Neither  in  this,  more  than  in  the 
preceding,  was  the  state  of  the  tongue  explained  by  the  state  of  the  stomach. 
In  this  case,  finally,  we  found  in  the  brain  traces  of  congestion  which  did  not 
exist  in  the  subject  of  the  second  case,  though  in  the  latter  case  the  different 
nervous  symptoms  were  still  more  marked. 

Among  the  other  alterations  discovered  on  opening  the  body,  we  shall  notice, 
1st,  the  very  peculiar  appearance  of  the  bile  ; 2dly,  the  great  size  and  extreme 
softness  of  the  spleen.  We  shall  not  find  the  same  alteration  of  the  bile  in  the 
following  cases  ; we  shall  find,  on  the  contrary,  a state  of  the  spleen  similar  to 
that  presented  to  us  in  the  present  case.  Now,  does  not  this  extreme  fre- 
quency of  the  same  alteration  in  one  and  the  same  species  of  disease,  prove  its 
importance?  Should  it  not  at  least  engage  the  attention  of  observers  ? 

The  treatment  was  purely  antiphlogistic;  during  the  first  days  diluent  drinks 
and  diet ; then  large  bleedings,  general  and  local  ; and  lastly,  revulsives.  How- 
ever, the  disease  continued  its  course.  Would  the  bloodletting  have  been  more 
successful,  if  employed  from  the  very  commencement?  We  may  suppose  it, 
but  who  would  venture  positively  to  affirm  it,  after  having  read  the  cases  pre- 
ceding this  case  ? There  were,  besides,  in  this  individual,  peculiar  conditions 
of  innervation,  which  existed  previous  to  his  disease  (his  habits  of  excess), 
and  which,  no  doubt,  were  not  without  their  influence  on  its  severity.  How- 
ever, we  should  not  exaggerate  this  influence  ; for  no  similar  cause  had  existed 
in  the  individual  who  forms  the  subject  of  the  second  case,  nor  in  the  two 
medical  students  whose  cases  are  mentioned  among  the  observations  appended 
to  that  case,  and  yet  in  those  three  individuals  disturbances  of  innervation 
equally  serious  manifested  themselves. 

Case  4.  — Symptoms  of  fever  at  first  mucous,  then  adynamic — Death  on  the  16th  day  — 
Tumefaction  of  the  follicles — Numerous  worms  in  the  intestine. 

A boy,  sixteen  years  of  age,  of  delicate  frame,  as  yet  presenting  no  signs  of 
puberty,  had  been  living  in  Paris  just  nine  days.  He  had  to  come  from  Lor- 
raine, and  travelled  in  an  open  vehicle.  Two  days  after  his  arrival  he  felt  some 
headach  and  uneasiness  in  the  throat.  At  the  same  time  there  was  loss  of 
appetite  and  fever  ; no  pain  in  the  abdomen  nor  diarrhcea.  After  having  re- 


DISEASES  OF  THE  ABDOMEN. 


23 


mained  for  seven  days  in  this  state,  he  entered  the  Charite,  and  then  presented 
the  following  state  : 

Headach  ; face  pale ; pupils  very  much  dilated  ; great  dejection  of  mind ; 
listlessness  in  moving;  tongue  whitish  ; thirst;  extreme  disgust  for  food  of 
every  kind  ; frequent  nausea  ; slight  uneasiness  in  the  throat ; abdomen  soft, 
and  free  from  pain  ; no  stool  for  the  last  six  days  ; fever  very  slight ; 
breathing  free  ; chest  sonorous  ; acute  pain  on  pressure  between  the  fourth 
and  fifth  ribs  external  to  the  breast,  to  the  extent  of  one  or  two  inches  at 
most;  can  lie  in  any  position.  (Twenty  leeches  to  the  anus;  tisane  d’orge 
oximelee.) 

The  next  day,  28th  of  February,  mouth  very  foul ; breath  fetid ; nausea  ; 
slight  diarrhoea  ; abdomen  swollen  ; pulse  scarcely  feverish  ; skin  dry  ; coun- 
tenance pale  ; eyes  heavy  ; general  debility  sensibly  increased.  (Ten  grains 
of  ipecacuanha  ; two  blisters  to  the  legs  ; embrocations  of  camphorated  oil  of 
camomile  to  the  abdomen.) 

The  patient  vomited  a little  bile,  and  went  to  the  night  chair  once  in  the 
twenty-four  hours. 

March  2d,  tongue  equally  loaded,  mouth  also  foul  ; pain  of  side  now  but 
very  slightly  felt  by  strong  pressure.  But  the  patient  was  now  despond- 
ent; he  had  had  some  delirium  during  the  night;  the  prostration  of  strength 
increased  ; the  features  were  perceptibly  changed  ; the  abdomen,  now  very 
large,  was  painful  on  pressure ; pulse  very  frequent  and  compressible ; skin 
dry  and  hot.  (Six  leeches  behind  each  ear;  embrocations  with  oil  of  sweet 
almonds  over  the  abdomen  ; emollient  fomentations;  tisane  d’orge  eduleoree.) 

A great  quantity  of  blood  flowed  from  the  leech  bites. 

Only  one  stool  took  place  up  to  the  next  morning. 

On  the  3d  day  the  patient  commenced  to  become  delirious;  at  night  he  was 
very  much  disturbed.  On  the  morning  of  the  4th,  the  face  was  dejected  and 
very  pale,  and  expressive  of  anxiety  ; the  patient  answered  questions  with  con- 
siderable difficulty  ; his  ideas  were  lucid  only  at  intervals  ; when  the  abdomen 
was  even  slightly  pressed  he  uttered  loud  cries ; the  pain  appeared  then  suffi- 
ciently acute  to  cause  us  to  suspect  peritonitis ; tongue  moist  and  yellowish  ; 
no  evacuations  by  stool.  (Flaxseed  ptisan  j emollient  lavements  and  fomen- 
tations.) 

Screaming  and  delirium  on  the  night  of  the  4th.  On  the  5th  the  delirium 
continued  ; features  changed ; eye  dull,  half  covered  by  the  upper  eyelid.  Pres- 
sure on  the  abdomen  caused  pain  ; pulse  very  frequent  and  weak ; skin  hot  and 
dry  ; tongue  still  moist;  patient  coughed  very  much. 

On  the  6th,  in  the  same  state  ; extreme  dilatation  of  the  pupils,  which  scarcely 
contracted  under  the  influence  of  the  light.  On  the  7th,  face  cadaverous  ; 
tongue  for  the  first  time  dry  and  covered  with  a brownish  coat ; intellects  quite 
gone  ; pulse  thready,  extremely  frequent.  Skin  moist  for  the  first  time  ; ab- 
domen soft,  no  stool ; respiration  hurried  ; cough  ; sibilous  rale  anteriorly  on 
both  sides.  He  died  in  the  evening. 

Post-mortem.  Nothing  remarkable  in  the  head. 

Considerable  engorgement  of  the  posterior  part  of  both  lungs,  particularly  of 
the  right ; heart  empty  as  well  as  the  arteries. 

Inner  surface  of  the  stomach  generally  white  ; slight  injection  of  the  mucous 
membrane  over  a small  extent  of  the  great  cul-de-sac. 

Considerable  redness  of  duodenal  mucous  membrane  ; nothing  remarkable  in 
the  upper  three-fourths  of  the  small  intestine ; sixty  ascarides  in  the  lower  fourth  ; 
in  this  portion  there  were  observed  numerous  elevations,  irregularly  rounded  or 
oval,  white,  projecting  one  or  two  lines  above  the  level  of  the  mucous  membrane, 
the  diameter  of  which  varied  from  that  of  a small  pin’s  head  to  that  of  a two 
franc  piece.  They  were  formed  by  thickened  mucous  membrane,  which  was 


24 


ANDRAL’S  MEDICAL  CLINIC. 


white  around  them  ; some  tricocephalous  worms  were  found  in  great  quantity  in 
the  large  intestine,  which  was  white  ; some  black  points,  crowded  together, 
such  as  we  have  already  described,  studded  the  mucous  membrane  of  the  ver- 
micular appendix  of  the  coecum. 

When  this  patient  entered  the  Charite,  nothing  was  observed  regarding  him 
but  general  debility,  a sort  of  languor  of  most  of  the  functions.  He  presented 
in  a manner  that  group  of  symptoms  described  under  the  name  of  mucous  fever. 
The  cause  of  this  state  was  found  to  be  the  fatigue  of  a long  and  painful  journey, 
and  probably  the  use  of  bad  diet.  After  some  days,  and  whilst  the  general 
debility  was  proceeding,  the  pulse,  scarcely  frequent  till  then,  became  accele- 
rated, delirium  manifested  itself,  first  at  intervals,  and  then  in  a continued  form, 
and  the  patient  died  in  an  ataxo-adynamic  state.  At  first  leeches  were  applied 
to  the  anus.  Well-marked  signs  of  gastric  disturbance  were  combated  by  a 
vomit.  Afterwards  blisters  were  applied  to  the  legs.  An  effort  was  made  to 
stop  the  delirium  by  bleeding  from  the  mastoid  region  and  the  neck.  We  have 
seen  the  lesions  found  on  opening  the  body.  Whilst  the  stomach  presented 
but  slight  injection,  and  one  of  but  small  extent,  the  tongue  was  dry  and  black 
towards  the  termination. 

Can  the  worms  be  considered  as  the  cause  of  the  disease  of  which  the  patient 
died  ? We  may  observe  that  a similar  state  has  been  observed  in  persons 
whose  intestines  contained  no  worm.  At  other  times,  on  the  contrary,  we 
have  found  the  intestines  filled  with  an  immense  quantity  of  lumbrici,  in  patients 
who  presented  none  of  the  symptoms  observed  in  this  case. 

Or  is  it  to  the  presence  of  worms  that  we  must  attribute  several  of  the  symp- 
toms, such  as  the  extreme  dilatation  of  the  pupils,  which  continued  from  the 
time  of  the  patient’s  admission  to  his  death,  the  livid  paleness  of  the  face,  and 
of  the  parts  around  the  orbits,  the  fetid  breath,  enlargement  of  the  abdomen,  its 
extreme  sensibility,  particularly  in  the  latter  periods  of  life?  We  have  often 
seen  this  latter  phenomenon  appear  in  several  cases  of  bad  fever  without  the 
existence  of  any  lesion  to  account  for  it.  The  patients  evinced  the  most  acute 
pain,  uttered  loud  cries  on  making  even  slight  pressure  on  the  abdomen  ; but  if 
we  made  the  same  degree  of  pressure  on  other  parts  of  the  body,  as  the  chest 
or  extremities,  they  did  not  bear  it  better.  This  general  feeling  of  pain  is  but 
the  result  of  an  exaltation  of  sensibility  ; in  other  persons,  on  the  contrary,  also 
labouring  under  ataxic  fever,  the  sensibility  is  so  far  abolished  that  one  may 
pinch  the  skin  with  the  utmost  severity,  and  even  run  sharp  bodies  into  it,  with- 
out the  patient  appearing  to  feel  any  pain. 

Is  it  again  to  the  worms  we  are  to  attribute  the  pleuritic  pain  of  which  the 
patient  complained  at  first,  and  the  cough  also  which  distressed  him  ? Mor- 
gagni, irrefragabilis  auctor , as  Haller  calls  him,  has  given  the  case  of  a young 
man,  who,  labouring  under  a cough  and  an  acute  pain  in  one  of  the  sides  of  the 
chest,  was  freed  from  both  after  vomiting  up  a lumbricous  worm.  This  fact 
should  not  be  admitted  except  with  some  reserve.  It  is  not  a matter  of  doubt, 
however,  that  most  of  the  symptoms  of  pulmonary  phthisis  may  be  simulated 
by  the  presence  of  taenia. 

Besides,  there  are  few  diseases,  particularly  in  children,  of  which  persons 
have  not  imagined  that  they  may  consider  worms  as  the  cause.  Klein  has  said  : 
Nullum  tarn  peregrinum  est  symptoma  tarnque  Sd.ty.ovi  tv,  quod  vermes  exci- 
tare  non  possint.  We  read  in  different  works  numerous  examples  of  paralysis, 
of  states  of  coma,  of  asthmas,  of  palpitations  of  the  heart,  of  obstinate  coughs, 
of  epilepsy,  hysteric  convulsions,  owing  to  this  cause.  There  is  no  disease, 
even  to  tetanus,  which  has  not  been  considered  as  resulting  from  the  presence 
of  worms  in  the  intestinal  canal.  Since  the  time  of  Alexander  of  Tralles,  it 
was  said,  that  when  worms  passed  from  the  small  intestine  into  the  stomach, 
they  gave  rise  to  severe  cardialgia,  to  syncope,  and  that  sudden  death  was 
sometimes  the  result  of  them. 


DISEASES  OF  THE  ABDOMEN-. 


25 


It  must  be  owned  that  such  observations  become  much  more  rare,  according 
as  pathological  anatomy  is  more  generally  and  more  carefully  cultivated.  But 
whilst  we  may  distrust  the  reality  of  these  extraordinary  facts,  we  should  take 
care  not  to  deny  the  possibility  of  them.  A hemiplegia  occasioned  by  worms 
should  not  appear  to  us  a more  incredible  phenomenon  than  paralysis  consecu- 
tive on  the  introduction  of  particles  of  lead  into  the  digestive  passages.  Now 
nothing  unfortunately  is  more  real  and  more  common  than  this  latter  species 
of  paralysis.  The  symptoms  caused  by  worms  must  vary  much  according  to 
their  nature,  their  number,  their  more  or  less  active  life,  their  greater  or  less 
mobility,  their  more  or  less  immediate  contact  with  the  mucous  membrane,  their 
situation  in  such  or  such  a part  of  the  digestive  tube,  the  activity  of  the  sym- 
pathies of  the  individual,  his  nervous  susceptibility,  etc.  Some  physicians, 
said  De  Ilaen,  make  worms  perform  too  important  a part  in  the  production  of 
diseases,  whilst  others  do  not  pay  sufficient  attention  to  them. 

In  our  patient,  the  portions  of  mucous  membrane  in  contact  with  the  worms 
were  very  white.  At  other  times  we  found  those  animals  plunged  in  a quantity 
of  bloody  mucus,  and  the  mucous  membrane  very  much  inflamed  around  them. 

Case  5. — Symptoms  of  ataxo-adynamic  fever — Death  towards  the  18th  day — Tumefaction  of 

the  follicles  of  the  small  intestine — Follicles  of  the  colon  more  apparent  than  usual — Spleen 

large  and  soft — Pneumonia. 

A coach-driver,  about  ^twenty-five  years  of  age,  was  brought  to  the  hospital 
in  a state  of  complete  delirium.  We  could  learn  nothing  regarding  his  previous 
state,  except  that  he  wTas  ill  for  the  last  fifteen  days.  The  eyes  were  injected, 
the  cheeks  red,  the  lips  dry,  tongue  moist.  He  passed  his  faeces  frequently 
under  him.  Pulse  weak  and  frequent;  skin  not  hot;  some  subsultus  tendinum. 
(Two  blisters  to  the  legs;  barley  water  with  gum  in  it.) 

On  the  next  day,  18th  December,  continuance  of  the  delirium  ; tongue  dry  ; 
pulse  very  frequent  and  very  weak. 

On  the  19th,  for  the  first  time,  the  patient  answered  questions,  though  still 
delirious.  He  had  a very  marked  air  of  stupor;  some  petechiae  on  the  epigas- 
trium ; breathing  hurried.  (Sinapisms.) 

On  the  20th,  the  last  degree  of  prostration  ; face  cadaverous  ; pulse  thready, 
and  so  frequent,  that  its  beats  were  beyond  counting;  tongue  dry  and  black; 
involuntary  stools. 

He  died  in  the  course  of  the  day. 

Post-mortem.  Brain  healthy;  a mixture  of  sero-sanguinolent  engorgement 
and  of  red  hepatisation  in  the  lower  lobe  of  the  right  lung. 

Slight  injection  of  the  great  cul-de-sac  of  the  stomach.  Perfect  whiteness  of 
the  upper  four-fifths  of  the  small  intestine  ; in  the  lower  fifth  several  elevations 
of  a red  colour  and  oval  form,  separated  by  intervals  in  which  the  mucous  mem- 
brane was  white.  No  ulcerations. 

Slight  injection  of  the  cascum  ; in  the  descending  colon  isolated  black  points 
on  the  centre  of  a slight  prominence  of  the  mucous  membrane  (follicles). 

Spleen  large  and  very  soft. 

The  subject  of  this  case  died  at  a period  more  remote  from  the  commencement 
of  the  disease  than  the  subjects  of  the  preceding  cases  ; however,  the  same  al- 
terations were  found  in  the  intestine  ; none  of  the  exanthematous  patches,  which 
were  observed  on  it,  as  yet  presented  any  ulceration  ; we  have  already  seen  a 
case,  where  the  disease  was  less  ancient,  and  yet  where  the  surface  of  these 
patches  presented  a slight  commencement  of  solution  of  continuity.  We  shall 
see  presently  other  instances  of  more  considerable  ulceration  also  at  a less  ad- 
vanced period. 

In  this  case  we  again  see  an  instance  of  delirium  without  any  appreciable 
lesion  of  the  encephalon,  and  a dry  black  tongue,  with  a state  of  stomach  such 
3 


26 


ANDRAL’S  MEDICAL  CLINIC. 


as  is  met  in  a number  of  cases,  in  which  the  tongue  never  changed  from  its  na- 
tural state.  Why  was  this  tongue  still  moist  on  the  day  the  patient  entered  the 
hospital  ? Why  from  the  next  day  was  it  found  so  dry  ? 

What  symptom  could  have  here  caused  one  to  suspect  hepatisation  of  a part 
of  the  right  lung?  A little  difficulty  of  breathing  the  day  before  his  death  was 
all  that  was  observed  with  respect  to  the  chest.  This  shows  the  necessity,  in 
such  cases,  to  practise  auscultation  and  percussion,  even  when  no  sign  induces 
us  to  suspect  the  existence  of  a disease  of  the  respiratory  organs.  Here,  also, 
it  may  be  observed,  that  no  other  plan  of  treatment  but  that  employed  could 
have  been  opposed  to  this  pneumonia ; the  symptoms  contra-indicated  the  em- 
ployment of  bloodletting  in  any  form,  and  the  revulsives  which  were  applied 
could  have  been  the  only  means  used  to  arrest  the  pneumonia. 

Case  6. — Symptoms  of  ataxo-adynamic  fever — Previous  distress — Progressive  derangement 
of  the  health — Death  from  the  25th  to  the  30th  day — Tumefaction  and  redness  of  the  intes- 
tinal follicles — Redness  of  the  splenic  portion  of  the  stomach,  and  of  the  mucous  membrane 
of  the  small  intestine  between  the  follicles — Red  spots  on  the  inner  surface  of  the  bladder — 
Spleen  large  and  soft — Pneumonia. 

A man,  fifty-five  years  of  age,  emaciated  and  of  a delicate  constitution,  had 
previously  been  in  tolerably  easy  circumstances  ; but  for  some  years  back  he  had 
been  plunged  into  great  distress,  and  now  subsisted  on  a small  pension,  which 
was  not  sufficient  to  satisfy  his  wants.  He  dwelt  in  a very  small  room,  situate 
very  close  to  infectious  privies.  However,  he  had  always  enjoyed  tolerably 
good  health,  when,  towards  the  end  of  August,  he  was  seized  with  violent  an- 
gina, after  plunging  his  feet  into  cold  water  whilst  they  were  in  a state  of  moisture. 
This  angina  was  removed  by  the  application  of  leeches  to  the  neck;  but  from 
that  time  he  continued  in  a delicate  state  of  health.  He  felt  at  intervals  head- 
achs,  severe  lumbar  pains,  and  lost  his  appetite;  his  strength  was  diminished. 
On  the  12th  September  he  was  attacked  with  diarrhoea,  which  continued  up  to 
the  18th,  when  he  entered  the  hospital.  During  this  time  he  had  not  more  than 
two  or  three  liquid  stools  every  twenty-four  hours.  On  the  morning  of  the  17th, 
he  presented  the  following  state ; 

Features  sunk  ; prostration  ; tongue  dry,  brown  in  its  centre  ; but  little  thirst; 
loss  of  appetite ; abdomen  free  from  pain  ; two  liquid  stools  since  the  last  twenty- 
four  hours  ; pulse  frequent  and  weak  ; but  little  heat  of  skin  ; a little  excitement 
in  his  ideas. 

Notwithstanding  the  adynamic  aspect  of  the  face,  and  the  brown  colour  of 
the  tongue,  fifteen  leeches  were  applied  to  the  anus.  (Emollient  lavement ; 
sweetened  barley  water.) 

On  the  next  day,  18th,  the  entire  upper  surface  of  the  tongue  was  black  ; in 
other  respects  his  state  was  the  same.  (Barley ; emollient  lavement.) 

No  stool  occurred  up  to  the  following  morning;  tongue  dry  and  black;  pros- 
tration still  increasing  ; pulse  very  weak  and  frequent;  skin  not  hot.  However, 
in  the  midst  of  the  general  adynamic  state,  his  ideas  were  still  excited ; the  pa- 
tient romanced  very  much  ; he  was  in  a state  bordering  on  delirium. 

M.  Lerminier  determined  on  unloading  the  brain,  on  the  one  hand,  and  on  the 
other  to  raise  the  strength  ; such  was  the  object  of  the  following  prescriptions: — 
Four  leeches  behind  each  ear;  two  sinapisms  in  the  evening  around  each  leg; 
frictions  of  camphorated  alcohol  on  the  extremities ; lavement  with  an  ounce  ol 
quinquina  and  a scruple  of  camphor ; barley  water,  with  a third  of  wine ; mineral 
lemonade. 

In  the  course  of  the  day  his  ideas  became  lucid  ; the  night  was  sufficiently 
calm.  On  the  20th  his  state  scarcely  changed.  (The  same  prescription,  except 
the  leeches.) 

The  following  twenty-four  hours  the  faeces  passed  involuntarily  three  or  four 


DISEASES  OF  THE  ABDOMEN. 


27 


times.  On  the  21st,  his  mind  still  excited;  the  dryness  and  blackness  of  the 
tongue  still  continued  ; pulse  thready  ; temperature  of  the  skin  as  usual.  (Two 
cups  of  infusion  of  quinquina,  with  the  addition  of  syrup  of  orange  peel.) 

On  the  22d,  23d,  and  24th,  no  change  in  the  patient;  three  or  four  alvine 
evacuations  in  the  twenty-four  hours  ; power  of  moving  still  remained  : could 
raise  himself  up  in  the  bed  on  his  elbow,  and  remain  in  that  position.  His  case 
did  not  yet  seem  hopeless.  (The  same  treatment  was  continued.) 

On  the  26th  the  tongue  was  moist,  and  had  partly  lost  the  black  appearance ; 
none  of  the  other  symptoms  were  aggravated.  He  died,  however,  on  the  27th, 
at  one  o’clock  in  the  morning. 

Post-mortem , thirty-two  hours  after  death. 

Cranium. — Sub-arachnoid  cellular  tissue  infiltrated  with  a little  serum.  Brain 
a little  soft,  not  injected,  neither  were  its  membranes.  About  two  spoonsful 
(cuillieres  a cafe)  of  limpid  serum  existed  in  each  lateral  ventricle.  Nothing 
remarkable  in  the  other  parts  of  the  encephalon. 

Thorax. — The  right  lung,  which  adhered  to  the  ribs  by  old  cellular  bands, 
was  perfectly  healthy;  it  was  not  even  engorged.  The  same  may  be  said  of  the 
anterior  part  of  the  left  lung;  but  posteriorly  its  tissue,  which  was  of  a deep 
brown,  was  engorged  with  a great  quantity  of  blood  ; it  scarcely  crepitated,  and 
was  broken  into  a pulp  when  pressed  between  the  fingers. — The  heart,  which 
was  well  proportioned,  contained  in  its  right  cavities  a white  fibrinous  clot  of 
considerable  consistence,  occupying  both  the  auricle  and  ventricle.  On  pressing 
this  clot  between  the  fingers,  a great  quantity  of  serum  was  forced  from  it,  and 
it  was  changed  into  an  albuminous,  thin  membrane.  Similar  clots  existed  in 
the  aorta,  the  inner  surface  of  which  was  white. 

Abdomen. — The  stomach  was  a little  covered  by  the  liver ; its  inner  surface 
was  white  in  the  pyloric  portion ; but  over  the  splenic  portion  numerous  vas- 
cular ramifications  appeared,  around  which  small  red  points  were  collected. 
Grouped  together  in  several  places  to  a considerable  number,  they  produced 
therein  a uniform  red  colour.  The  vascular  ramifications  were  seated  in  the 
laminated  tissue,  and  the  red  points  in  the  mucous  membrane;  small  injected 
vessels  formed  them.  The  membrane,  which  was  of  considerable  thickness, 
was  detached  every  where  without  being  torn.  It  appeared  manifest  that  in- 
flammation in  the  first  stage  existed  in  about  two-thirds  of  the  stomach. 

The  small  intestine  presented  a white  colour,  of  a slightly  rose  tint  at  intervals, 
to  the  extent  of  a foot  and  a half  above  the  caecum.  Over  this  space  the  mucous 
membrane  presented  an  intensely  red  colour,  and  a greater  thickness  than  na- 
tural. In  three  places  there  were  found  oblong  elevations,  red  as  the  rest  of 
the  membrane,  being  four  lines  in  length  to  one  or  two  in  breadth.  They 
would  probably  have  been  changed  into  ulcerations,  if  the  individual  had  lived 
a longer  time. 

Immediately  below  the  ileo-caecal  valve,  the  inner  surface  of  the  intestine 
changed  its  appearance.  Instead  of  a uniform  red  colour,  we  observed,  on  a white 
ground,  a number  of  very  small  red  patches,  of  a truly  miliary  size,  rounded, 
oblong,  or  sinuous,  the  middle  of  which  presented  a white  tint  similar  to  the 
colour  of  the  mucous  membrane  in  the  interval  between  the  patches.  This  al- 
teration existed  from  the  caecum  to  the  sigmoid  flexure  of  the  colon.  The  rest 
of  the  large  intestine  was  white : it  was  filled  with  liquid  greenish  matter. 

The  liver  was  remarkably  hard  ; three  small  calculi,  two  miliary,  and  the  third 
the  size  of  a nut,  were  contained  in  the  gall-bladder.  The  spleen,  which  was 
large,  was  reduced  to  a reddish  pap  by  the  slightest  pressure.  The  bladder 
contained  a small  quantity  of  urine  : its  inner  surface  was  marked  with  a great 
number  of  spots  of  a vermilion  red,  similar  to  those  sometimes  found  in  the 
stomach. 

It  is  impossible  to  mark  in  this  case  the  precise  time  when  the  intestinal  lesion 


2S 


ANDRAL’S  MEDICAL  CLINIC. 


commenced.  In  this  patient,  who  was  placed  in  conditions  which  predisposed 
him  to  severe  disease,  we  at  first  perceive  the  health  to  become  deranged  by  little 
and  little ; symptoms  then  supervened  one  after  the  other  with  respect  to  the 
organs  of  deglutition,  on  the  part  of  the  head,  the  loins,  and  then  the  digestive 
tube : ultimately,  the  lesion  of  the  latter  part  continued,  and  became  predominant. 

When  the  patient  entered  the  hospital,  he  already  presented  that  group  of 
symptoms,  which,  in  Pinel’s  school,  characterise  the  adynamic  state,  and  deli- 
rium soon  came  on.  During  the  first  days  mere  emollients  were  prescribed,  the 
state  of  the  patient  became  worse  ; tonics  were  tried ; these  at  first  were  not  more 
serviceable.  However,  it  is  worthy  of  remark,  that  two  days  after  commencing 
the  use  of  quinquina  by  the  mouth,  the  tongue  began  to  become  moist  and  to  lose 
its  black  coating  ; and,  under  the  influence  of  this  medicine,  the  diarrhoea  did  not 
increase.  How  are  we  to  explain  this  change  in  the  appearance  of  the  tongue, 
after  the  administration  of  the  quinquina,  if  we  reflect  on  the  intensely  red  state 
of  the  stomach,  as  seen  in  the  post-mortem  ? Is  it  the  medicine  itself  which 
produced  this  redness  ? The  tolerably  good  state  of  the  strength,  the  free  power 
of  motion,  still  allowed  some  hope  of  recovery,  when  on  a sudden  the  patient 
died.  What  part  did  the  lung  affection  perform  in  the  production  of  the  symp- 
toms and  of  death  ? We  cannot  tell ; but  here,  again,  the  pulmonary  affection 
remained  completely  latent,  and  was  not  discovered  till  after  death.  The  state 
of  the  lung  was  very  remarkable  ; it  was  rather  a sort  of  pultaceous  softening 
than  a true  hepatisation. 

The  noxious  influences  of  air  and  diet  to  which  this  person  had  been  exposed 
a long  time  before  he  became  sick,  the  distress  which  he  had  experienced,  might 
incline  one  to  think  that  in  him  the  first  movement  of  derangement  of  the  health 
had  been  a badly  repaired  state  of  the  blood.  This  was  one  of  the  cases  in  which, 
a priori , one  might  admit  an  alteration  of  the  blood  as  a primary  cause  of  the 
morbid  phenomena,  and  in  which  one  might  have  expected  to  find  it,  after  death, 
different  from  what  it  is  in  the  normal  state.  However,  it  was  not  so ; if  the  blood 
was  altered,  it  was  not  at  least  altered  in  a manner  appreciable  by  our  senses  : let 
us  recollect,  accordingly,  the  fibrinous  clot  of  natural  colour  and  consistence, 
which  filled  the  cavities  of  the  heart.  In  the  diseases  similar  to  those  of  which 
the  preceding  case  is  an  instance,  and  which,  in  a language  purely  symptomatic, 
have  been  called  typhoid  fevers,  the  blood  does  not  then  always  lose  the  property 
of  coagulating  after  death,  as  has  been  asserted,  and  it  cannot  be  established  as  a 
principle  that,  under  such  circumstances,  it  is  found  liquid  in  the  vessels.  Say, 
if  you  will,  that  in  those  diseases  the  alteration  of  the  blood  may  be  admitted, 
either  from  the  study  of  the  causes,  or  that  of  the  symptoms  ; but  acknowledge 
that,  in  many  cases  at  least,  it  is  solely  by  reasoning,  and  not  by  material  proofs, 
that  you  are  led  to  admit  this  alteration.  In  a subsequent  part  of  this  work,  we 
shall  find  other  cases  where  the  blood,  examined  on  the  dead  body,  will  present 
in  its  physical  properties  modifications  which  will  not  suffer  us  to  call  in  ques- 
tion its  real  alteration. 

Case  7. — Symptoms  of  fever  at  first  inflammatory,  then  ataxo-adynamic — Death  on  the  thirty- 
first  day — Constant  absence  of  diarrhoea — Tongue  dry  only  on  the  two  last  days — At  first 
copious  bleeding,  then  stimulant  treatment — Tumefaction  of  the  intestinal  follicles;  livid 
redness  of  the  inner  surface  of  the  caecum  and  colon — Redness  and  softness  of  the  mucous 
membrane  of  the  stomach. 

A sawyer,  twenty-four  years  of  age,  was  sick  for  ten  days  previous  to  his 
entering  the  Charite;  during  this  time  he  complained  of  headach,  lassitude,  and 
burning  heat  over  the  entire  body  ; on  his  admission  he  had  considerable  fever; 
stools  natural,  abdomen  soft  and  free  from  pain.  At  first  we  merely  gave  him 
demulcent  ptisans.  On  the  fourth  day,  the  8th  of  October,  twelve  leeches  were 
applied  to  the  anus. 


DISEASES  OF  THE  ABDOMEN. 


29 


On  the  9th,  headach  less ; had  a tranquil  night ; fever  less  ; tongue  whitish, 
red  only  at  the  apex;  two  stools.  (Barley  ptisan.) 

During  the  night  of  the  9th,  slight  delirium.  On  the  morning  of  the  10th, 
some  depression  ; pulse  as  it  were  rebounding,  and  of  moderate  frequency  ; 
tongue  covered  with  a yellowish  coat.  (Bleeding  from  the  foot  to  the  amount 
of  three  palettes.) 

The  night  of  the  10th  was  more  tranquil  than  the  preceding  night.  On  the 
11th  the  countenance  was  better,  intellects  and  speech  clearer  and  more  distinct. 
But  an  inflammatory  disposition  seemed  to  exist  at  once  in  several  organs  ; the 
patient  coughed  much  ; eyes  red,  as  also  the  lips  and  tongue.  Fever  not  in- 
tense ; pulse  retained  the  same  character,  it  seemed  as  it  were  to  rebound 
under  the  finger ; another  bleeding  appeared  to  be  indicated  ; two  palettes  of 
blood  were  drawn  from  the  arm,  the  blood  resembled  a soft  clot,  without  a buffy 
coat.  (Honied  borage,  barley  ptisan  with  oxymel.) 

During  the  day  the  patient  relapsed  into  the  same  state  of  depression  as  on 
the  10th  : in  the  night  his  intellects  again  became  disturbed,  On  the  morning 
to  the  12th,  he  answered  questions  with  difficulty;  his  voice  was  tremulous  ; 
commencing  stupor  was  imprinted  on  his  countenance.  The  tongue  was  red 
at  the  edges,  white  at  the  centre  ; abdomen  free  from  pain  ; one  stool;  pulse 
of  moderate  frequency  ; continuance  of  the  cough.  The  brain  appeared  to  be 
the  organ  principally  affected.  (Sinapisms  to  the  lower  extremities.) 

No  change  occurred  during  the  day  ; in  the  night  violent  hiccup  manifested 
itself,  which  still  continued  on  the  morning  of  the  13th  ; the  same  state  in  other 
respects.  (Blister  between  the  shoulders.) 

The  hiccup  had  not  ceased  on  the  14th  ; the  patient  raved  in  the  night;  his 
features  became  quite  immovable;  his  eyes  avoided  the  light;  the  tongue, 
which  was  moist,  presented  only  a slight  redness  at  its  edges ; the  abdomen 
began  to  become  tympanitic  ; no  stool  ; pulse  very  compressible,  and  ninety- 
two  ; temperature  of  the  skin  almost  natural.  The  following  mixture  was  pre- 
scribed, to  be  taken  in  spoonfuls  : orange-flower  water,  three  ounces ; mint 
water,  two  ounces;  tincture  of  musk,  one  drachm  (gros);  laudanum,  twelve 
drops  ; syrup  of  violets,  one  ounce. 

After  the  third  spoonful  w’as  taken,  the  hiccup  disappeared. 

In  the  course  of  the  day,  a lavement  of  camomile  with  the  addition  of  twelve 
grains  of  camphor  was  given.  The  patient  drank  some  mineral  lemonade  and 
wine  very  much  diluted. 

On  the  15th  the  hiccup  had  not  re-appeared.  (Same  prescription.) 

On  the  three  following  days,  the  state  of  the  patient  was  unchanged. 
(The  same  medicines  ; fomentations  of  camphorated  oil  of  camomile  on  the  ab- 
domen.) 

On  the  19th,  the  mixture  was  replaced  by  four  boluses  of  camphor  and 
nitre,  containing  each  six  grains  of  camphor,  and  six  of  nitre,  one  to  be  taken 
every  third  hour.  Tongue  nearly  natural ; abdomen  sufficiently  soft ; stools 
regular  ; pulse  compressible,  and  from  ninety  to  ninety-five ; countenance  still 
dejected. 

On  the  20th  and  21st,  the  air  of  stupor  visibly  increased,  without  the  other 
symptoms  presenting  any  change.  (Aqueous  infusion  of  quinquina ; mineral 
lemonade  ; barley  water ; camphorated  lavement ; aromatic  frictions  to  the  ex- 
tremities.) 

On  the  22d,  pulse  104  ; same  state  in  other  respects,  (Same  prescription.) 

In  the  night  the  patient  had  for  the  first  time  a profuse  sweat ; it  was  con- 
fined, however,  to  the  face,  chest,  and  upper  extremities;  it  was  far  from  being 
critical ; frequency  of  the  pulse  still  increased,  it  being  now  120  ; tongue  be- 
coming dry.  (Same  prescription.) 

3* 


30 


ANDRAL’S  MEDICAL  CLINIC. 


On  the  24th,  features  altered  ; spirits  very  much  dejected  ; tongue  entirely 
dry  ; pulse  142.  (Blisters  to  the  legs.) 

He  died  on  the  morning  of  the  25th. 

Post-mortem.  Nothing  remarkable  in  the  brain.  Lungs  engorged  poste- 
riorly. Heart  flaccid  and  empty. 

Abdomen . — Stomach  distended  with  the  liquids  he  had  taken,  and  with  gas. 
The  entire  mucous  membrane  red  and  soft ; beneath  it  the  laminated  tissue  per- 
ceptibly injected.  The  small  intestine  was  pale,  and  free  from  any  lesion  as  far 
as  half  a foot  above  the  ileo-caecal  valve.  In  this  part  the  mucous  membrane 
presented  numerous  white  elevations  surrounded  by  an  equally  white  tissue. 
The  surfaces  of  these  elevations  were  as  if  wrinkled,  and  uneven  ; their  form 
was  oblong;  their  diameter  equalled  that  of  a twenty  sous  piece.  The  mucous 
membrane  assumed  a brown  colour,  to  the  extent  of  two  or  three  fingers’  breadth 
at  most,  above  the  valve.  The  inner  surface  of  the  caecum,  and  ascending  colon, 
presented  an  intensely  livid  redness  ; the  remainder  of  the  large  intestine,  which 
was  filled  with  faecal  matter  of  considerable  consistence,  was  white. 

This  case  resembled,  at  its  commencement,  several  of  those  already  detailed. 
There  was  observed  headach,  general  uneasiness,  fever,  loss  of  appetite,  and 
nothing  else  connected  with  the  digestive  organs. 

These  symptoms,  combatted  at  first  by  means  of  simple  diluents,  continued; 
they  were  those  characterising  inflammatory  fever,  as  it  is  described  by  Pinel. 
They  were  diminished  after  the  application  of  leeches  to  the  anus  ; but  this 
amendment  was  but  temporary.  Two  days  after  the  application  of  the  leeches, 
all  the  symptoms  re-appeared  with  increased  intensity  ; the  pulse  in  particular 
presented  that  special  character  often  connected  with  hemorrhage,  and  which 
seemed  to  indicate  the  employment  of  bloodletting  ; a bleeding  from  the  foot  was 
accordingly  employed,  and  was  followed  by  an  improvement  in  the  state  of  the 
patient ; above  all,  the  strength  seemed  to  be  increased  ; one  would  then  naturally 
think  that  it  was  only  oppressed ; and  as  several  organs  still  seemed  threatened 
with  inflammation,  one  would  reasonably  suppose  that  another  bleeding  would 
prove  as  serviceable  as  the  two  preceding;  this  was  accordingly  employed,  but 
not  with  the  same  results.  A few  hours  after  its  employment,  the  symptoms 
became  frightfully  worse,  and  we  almost  instantaneously  saw  an  inflammatory 
fever,  which  appeared  not  at  all  severe,  become  changed  into  a well  marked  ataxo- 
adynamic  fever;  the  pulse  suddenly  changed  its  character;  it  became  small,  and 
no  longer  resisted  the  pressure  of  the  finger.  A little  meteorism  supervened  ; no 
other  appreciable  symptom  connected  with  the  digestive  organs.  Then  another 
plan  of  treatment  was  resorted  to.  Tincture  of  musk  was  given  for  the  special 
purpose  of  combatting  the  hiccup  which  a blister  had  not  removed.  This  hiccup 
ceased  accordingly  a little  after  we  commenced  the  use  of  this  substance  com- 
bined with  a little  laudanum.  Different  stimulants,  such  as  camphor,  nitre, 
wine  diluted  with  water,  sulphuric  lemonade,  were  then  given.  For  four  days 
the  disease  remained  stationary.  The  tongue  presented  an  almost  natural  ap- 
pearance; abdomen  soft;  stools  regular;  but  the  pulse  still  retained  its  frequency. 
The  air  of  stupor  did  not  first  diminish  ; it  afterwards  increased.  Recourse  was 
then  had  to  infusion  of  quinquina.  The  very  day  he  eommeneed^to  take  it,  the 
frequency  of  the  pulse  evidently  increased  : the  day  after  it  was  still  greater. 
The  tongue  became  dry,  for  the  first  time,  and  the  patient  died  in  a state  of 
prostration  which  suddenly  became  extreme. 

The  post-mortem  showed  the  same  lesion  in  the  intestinal  follicles  as  in  the 
subjects  of  the  preceding  cases.  It  also  showed,  in  a part  of  the  large  intestine,  a 
ledness  which  is  so  much  the  more  remarkable,  as  the  individual  had  never  had 
diarrhoea;  finally,  the  autopsy  discovered  to  us  a morbid  state  of  the  stomach, 
more  intense  than  in  any  of  the  preceding  cases.  Is  it  not  a remarkable  circum- 
stance, that  it  is  in  the  two  first  subjects  who  took  quinquina  that  we  found  the 


DISEASES  OF  THE  ABDOMEN. 


31 


stomach  more  diseased  than  in  any  of  the  others  ? I would  be  inclined  to  think 
that  it  was  only  towards  the  last  period  that  the  gastritis  set  in,  and  that  it  was 
of  it  the  patient  died.  We  have  found  the  stomach  healthy,  and  the  small  intes- 
tine exanthematous  in  other  persons  who  had  had  the  tongue  dry  and  black. — 
Here  we  may  suppose  that  the  period  at  which  the  tongue  began  to  dry  coincided 
with  the  development  of  the  gastric  irritation.  But  why  did  it  remain  in  an 
almost  natural  state  whilst  there  was  only  exantheme  of  the  intestine?  There 
are  then  other  conditions,  which,  independently  of  the  existence  of  this  exan- 
theme, may  cause  a singular  change  in  the  state  of  the  tongue.  It  is  those  same 
conditions,  which  may  be  supposed  to  reside  in  the  innervation,  which,  with  a 
lesion  similar  in  its  nature,  in  its  degree,  in  its  seat,  and  in  its  extent,  impressed 
so  different  an  aspect  on  the  diseases  mentioned  in  the  preceding  cases. 

Case  8.  — Febrile  diarrhoea  at  the  time  of  admission  — Improvement  by  means  of  diet  and 
diluent  drinks  — Suddenly  severe  nervous  symptoms  and  death  — Indeterminate  duration 
of  the  disease  — Treatment  by.  bloodletting  and  revulsives  — Tumefaction  of  the  intestinal 
follicles  — Small  red  spots  in  the  stomach  — Spleen  large  and  soft — Blood  liquid. 

A man,  twenty-eight  years  of  age,  who  had  recently  come  to  Paris,  entered 
the  Charite  in  the  month  of  November,  with  slight  purging  and  very  little  fever. 
Both  were  nearly  checked  by  diet  and  diluents,  when,  without  any  known 
cause,  the  patient  fell  into  the  greatest  despondency  ; from  thenceforward  he  was 
convinced  that  his  death  was  near  at  hand,  and  inevitable.  However,  the  pulse 
had  not  become  frequent.  This  state  of  mind  continued  for  two  days.  Every 
effort  was  used,  but  in  vain,  to  persuade  the  patient  that  his  fears  had  no  foun- 
dation.— On  the  third  day,  Nov.  23,  his  intellects  became  disturbed;  pulse 
became  hurried  : the  next  day  there  was  intense  fever  ; a little  diarrhoea  always 
remained  ; intellects  more  disturbed.  On  the  25th,  complete  delirium  : at  six 
in  the  morning  the  patient  was  found  out  of  his  bed,  to  which  by  our  remon- 
strances he  returned  ; and,  though  answering  our  questions  with  considerable 
clearness,  he  was  evidently  still  disturbed  in  his  ideas  ; his  eye  haggard  ; pulse 
very  frequent ; skin  very  hot ; face  covered  with  a profuse  sweat;  tongue  still 
moist,  and  its  apex  red. 

On  the  26th,  he  lay  on  his  back,  his  eye  fixed,  and  his  look  melancholy  ; face 
red,  and  covered  with  sweat;  he  viewed  those  around  him  with  a disdainful  and 
angry  frown,  and  refused  to  answer  questions  or  to  show  his  tongue  ; when 
questioned  he  frowned,  and  uttered  with  a strong  voice  some  unconnected  words  ; 
arterial  pulsations  so  frequent  that  they  can  be  no  longer  counted ; death  occurred 
on  the  following  night. 

Dating  from  the  23d  of  November,  leeches  were  several  times  applied  to  the 
neck  and  to  the  anus  ; the  leeches  were  covered  with  blisters  ; simple  diluents 
were  given  internally. 

Post-mortem.  Muscles  were  brown  and  gluey  ( poisseux ). 

The  brain  and  its  membranes  presented  no  appreciable  lesion. 

Lungs  engorged  posteriorly.  A considerable  number  of  veins,  gorged  with 
blood,  passed  over  the  cellular  tissue  subjacent  to  the  mucous  membrane  of  the 
stomach.  The  latter  membrane  presented,  towards  the  great  cul-de-sac,  five  or 
six  red  patches,  in  other  parts  it  was  white  and  healthy.  The  small  intestine 
was  healthy,  to  within  a foot  above  the  ileo-caecal  valve.  In  this  part  there  was 
observed  a number  of  elevations  of  different  appearances.  Some  of  them,  red  and 
conical,  were  nearly  the  size  of  a pea  ; others,  similar  to  the  preceding  in  form 
and  extent,  differed  from  them  in  the  whiteness  of  their  colour.  Others,  much 
larger,  round  or  oblong,  red,  or  of  a duller  white  than  the  rest  of  the  membrane, 
had  a diameter  equal  to  that  of  a ten  sous  piece  for  the  smaller,  and  of  a five  franc 
piece  for  the  larger.  In  the  intervals  between  them,  the  mucous  membrane  waa 
sometimes  white  and  sometimes  red.  This  eruption,  at  first  distinct,  became 


32 


ANDRAL’S  MEDICAL  CLINIC. 


confluent  near  the  valve.  Immediately  above  the  latter,  several  elevations  were 
combined  into  a single  one,  so  as  to  form  a large  patch,  which  occupied  nearly 
the  entire  round  of  the  intestine. 

The  caecum  was  very  much  injected  ; the  mesenteric  ganglions  were  red  and 
engorged.  The  spleen  was  remarkable  for  its  size  and  extreme  softness. — A 
liquid  black  blood  was  found  in  the  aorta,  as  also  in  the  heart,  the  tissue  of 
which  was  pale  and  flaccid. 

This  case  presents  three  stages.  — In  the  first,  the  digestive  passages  appear  to 
be  especially  affected,  and  the  fever  to  be  merely  symptomatic  of  the  intestinal 
irritation  evinced  by  the  diarrhoea.  At  this  stage  the  case  presents  nothing 
serious  ; diet  and  some  diluents  suffice  to  diminish  the  purging,  and  to  calm  the 
fever.  Then  commences  the  second  stage,  during  which  one  might  reasonably 
suppose  that  the  patient  is  becoming  convalescent.  It  is  then  that  the  mental 
dejection,  into  which,  without  any  known  cause,  the  patient  fell  all  at  once, 
appears  as  a prelude  to  a state  of  delirium,  in  the  midst  of  which  the  patient  dies. 
This  mental  dejection,  so  far  from  being  the  cause  of  the  nervous  symptoms, 
was,  probably,  itself  one  of  the  symptoms  of  the  cerebral  affection,  which,  how- 
ever, escaped  all  anatomical  investigation.  The  brain,  the  functions  of  which 
had  been  so  perceptibly  disturbed  up  to  the  time  of  death,  appeared  healthy 
under  the  scalpel.  What  did  we  find  to  account  for  such  serious  functional  dis- 
turbances ? Nothing  but  some  slight  red  spots  in  the  stomach,  and,  as  in  all 
the  other  cases,  an  engorgement  of  some  intestinal  follicles.  In  all  this  where 
is  the  cause  of  the  symptoms  ? Very  probably,  as  the  former  case  mentioned, 
and  some  others  to  be  mentioned  hereafter,  tend  to  prove,  at  the  time  the  patient 
entered  the  hospital,  he  already  carried  in  the  intestine  most  of  the  lesions  found 
there  after  death : yet  there  was  then  no  serious  symptom,  and  those  which  did 
exist  yielded  to  the  most  simple  means.  Did  the  intestinal  exantheme  suddenly 
take  on  a rapid  degree  of  increase  after  having  first  retrograded,  or  at  least  after 
having  remained  stationary  ? If,  in  this  case,  there  is  obscurity  in  explaining 
the  symptoms,  is  there  not  much  more  difficulty  in  accounting  for  death  ? The 
patient  died  when  he  was  still  full  of  life,  when,  a little  time  before  expiring,  the 
energy  of  his  movements,  and  the  strength  of  his  voice,  prevented  us  from  fore- 
seeing so  rapidly  fatal  a termination. 

In  fine,  what  relations  are  there  between  the  symptoms  and  death  in  this  case, 
and  the  state  in  which  the  blood  and  spleen  were  found  ? 


SECTION  II. 

CONTINUED  FEVERS,  WITH  LESION  OF  THE  FOLLICLES  IN  THE  STAGE  OF 

ULCERATION. 

In  the  cases  now  mentioned,  we  have  seen  a lesion  always  identical  coincide 
with  the  symptoms  of  different  continued  fevers.  In  the  persons  who  died  towards 
the  sixth  day,  as  in  those  who  died  after  the  thirtieth,  we  found  this  lesion  always 
similar  to  itself.  The  lesion  observed  was  uniformly  follicles,  which  were  become 
more  prominent  on  the  surface  of  the  mucous  membrane,  but  the  texture  of  which 
was  readily  recognised.  In  the  cases  which  are  to  follow,  we  shall  find  something 
else  : the  follicular  layer,  whether,  after  having  been  changed  into  a hard,  grey, 
brown  or  black  mass,  similar  to  an  eschar,  or  without  having  undergone  this 
change,  and  without  being  gangrenous,  shall  disappear,  and  in  its  place  we 
shall  find  ulcerations  very  variable  in  their  extent,  though  varying  but  little  in 
their  form  and  their  seat.  Often  also  we  shall  find  other  ulcerations  occupying 
the  place  of  a certain  number  of  isolated  follicles,  the  destruction  of  which  we 


DISEASES  OF  THE  ABDOMEN, 


33 


shall  be  able  to  trace  from  the  summit  to  the  base.  By  reading  these  different 
cases  vve  shall  soon  satisfy  ourselves  that  the  transition  of  the  follicular  disease 
into  the  state  of  ulceration  does  not  happen  at  a period  always  the  same.  Thus, 
as  we  have  already  seen,  there  are  cases  where,  after  more  than  thirty  days’ 
duration,  no  follicular  patch  is  as  yet  ulcerated  ; there  are  other  cases,  on  the 
contrary,  where,  a very  few  days  after  their  development  commenced,  they 
came  to  be  ulcerated. — We  shall  commence  by  citing  a case  of  this  latter 
kind,  in  which,  on  an  exanthematous  patch,  there  was  found  but  one  single  ul- 
ceration of  very  small  extent,  which,  by  increasing  in  depth,  produced  a fatal 
perforation.  This  should  be  compared  with  a former  case,  where  an  inter- 
current pneumonia  gave  rise  also  to  a premature  death.  Both  seem  to  us  im- 
portant, inasmuch  as  they  show  that  at  a period  of  fever  not  at  all  far  advanced, 
and  when  there  as  yet  exist  but  very  mild  symptoms,  there  exists  in  the  intes- 
tine the  same  lesion  as  that  discovered  in  cases  infinitely  more  alarming. 

Case  9.  — Slight  continued  fever  — Yellow  coating  of  the  tongue;  constipation  at  first,  then 
slight  diarrhoea  — Tumefaction  of  the  follicles  ; one  single  ulceration  on  one  of  the  patches, 
which  terminated  in  perforation  of  the  intestine  — Death  by  peritonitis  on  the  thirteenth 
day  of  the  fever  — Communication  between  the  digestive  tube  and  the  peritoneal  cavity  — 
Pulmonary  tubercles. 

A man,  about  eighteen  years  old,  of  a lymphatico-sanguineous  temperament, 
had  always  enjoyed  very  good  health.  On  the  13th  of  October,  at  seven  in 
the  evening,  he  felt  dizziness  and  general  uneasiness.  All  the  night  he  expe- 
rienced a burning  heat.  The  day  after,  in  the  same  state  ; anorexia,  one  alvine 
evacuation  ; profuse  sweat  at  night.  On  the  15th  he  entered  the  Charite.  He 
again  perspired  on  the  night  of  the  15th.  On  the  visit  of  the  16th,  he  presented 
the  following  state : — 

Face  red,  eyes  very  bright;  aching  of  the  limbs  ; tongue  covered  with  a yel- 
lowish thick  coat ; lips  red,  bad  taste  in  the  mouth;  anorexia;  little  thirst ; 
abdomen  soft,  and  free  from  pain  ; no  stool  for  the  last  twenty-four  hours  ; pulse 
frequent,  tolerably  full  ; skin  moist. 

After  a lavement  having  been  given,  the  patient  had  but  one  stool  up  to  the 
next  morning.  On  the  17th,  six  grains  of  ipecacuanha  were  given  ; the  patient 
vomited  twice  a considerable  quantity  of  bile;  he  did  not  go  to  stool.  In  the 
night  he  slept  well ; he  awoke  in  a state  of  moisture. 

The  next  morning,  the  yellowish  coating  of  the  tongue  was  gone;  it  was 
now  of  a fine  vermilion  colour  ; bad  taste  of  the  mouth  gone  ; pulse  not  frequent; 
temperature  of  the  skin  nearly  natural. 

From  the  19th  to  the  23d,  a slight  febrile  disturbance  continued  ; anorexia; 
same  state  of  the  tongue.  A stool  each  day  after  the  lavement.  (Demulcent 
ptisans,  &c.) 

On  the  23d  the  tongue  was  red  ; the  frequency  of  the  pulse  had  increased 
considerably;  skin  burning  hot ; abdomen  painful  on  pressure.  Two  liquid 
stools  took  place  within  the  last  twenty-four  hours.  This  exasperation  of  the 
symptoms  was  combatted  by  the  application  of  eight  leeches  to  the  anus.  (Bar- 
ley ptisan  ; diet.) 

In  the  day  the  abdominal  pains  assumed  a frightful  intensity.  The  patient 
began  to  vomit,  during  the  night,  a great  quantity  of  green  bile. 

On  the  morning  of  the  24th,  we  found  him  lying  on  the  right  side  ; eye  quite 
extinct;  countenance  pale  and  cadaverous.  The  slightest  pressure  on  the  ab- 
domen, or  the  least  motion,  excited  the  most  intense  pain.  Continual  nausea 
harassed  the  patient,  which  was  followed  from  time  to  time  by  some  bilious 
vomiting.  The  respiration,  which  was  high  and  hurried,  was  performed  solely 
by  raising  the  ribs  ; pulse  very  frequent  and  weak  ; skin  not  hot. 

The  presence  of  peritonitis  no  longer  questionable.  M.  Lerminier  suspected 


34 


ANDRAL’S  MEDICAL  CLIMC. 


the  cause  to  be  perforation  of  the  intestine.  (Forty  leeches  to  the  abdomen  ; 
oily  fomentations  ; mild  sinapisms  to  the  legs  in  the  evening;  flaxseed  ptisan.) 

The  vomiting  continued  for  the  entire  day.  On  the  25th,  at  nine  in  the  morn- 
ing, abdomen  less  painful  on  pressure,  but  it  was  increased  in  size,  and  pre- 
sented a shining  appearance  ; on  percussion  it  yielded  in  every  part  a dull 
sound  ; no  fluctuation  perceptible.  Extremities  cold,  pulse  thready.  The  eye, 
however,  still  retained  a somewhat  natural  expression:  intellect  clear,  speech 
free.  (Blisters  to  the  thighs.)  He  died  at  five  in  the  evening. 

Post-mortem , fifteen  hours  after  death.  Albuminous  flocculi,  extended  like 
false  membranes,  united  the  convolutions  of  the  small  intestine  to  each  other. 
A turbid,  milky,  very  foetid  serum  was  effused  into  the  two  flanks,  and  into  the 
cavity  of  the  lesser  pelvis.  Beneath  the  albuminous  flocculi,  the  peritoneum 
was  intensely  injected. 

Mucous  membrane  of  the  stomach  healthy  ; over  the  extent  of  about  one  foot 
above  the  ileo-caecal  valve,  there  existed  from  five  to  six  oval  elevations  of  a 
white  colour,  as  also  in  the  mucous  membrane  which  surrounded  them.  The 
centre  of  one  of  them  was  ulcerated  ; the  bottom  of  this  ulcer,  formed  by  the 
serous  membrane,  presented  at  its  centre  a round  perforation,  from  a line  and  a 
half  to  two  lines  in  diameter.  Around  these  elevations,  the  mucous  membrane 
was  studded  with  several  small,  white,  miliary  pustules,  scarcely  forming  a 
projection  above  its  surface. 

A tuberculous  mass,  the  size  of  a small  nut,  was  found  in  the  summit  of  the 
right  lung. 

The  principal  circumstance  which  renders  this  case  interesting,  is  the  exist- 
ence of  a well-marked  dothinenterite  in  an  individual,  who,  up  to  the  period  of 
the  attack  of  the  peritonitis,  presented  merely  the  symptoms  of  a continued  fever 
apparently  mild.  It  was,  with  respect  to  the  symptoms,  a slight  bilious  fever  ; 
the  abdomen  was  soft  and  free  from  pain  in  every  point.  The  tongue,  free 
from  redness,  presented  a thick  coat,  which  disappeared  after  a gentle  vomit. 
After  the  use  of  this,  the  gastric  symptoms  disappeared  ; but  a little  fever  re- 
mained, and  presently  a slight  diarrhoea  succeeded  to  the  constipation  which 
existed  since  the  commencement  of  the  disease.  It  was  from  the  tenth  to  the 
eleventh  day  that  this  purging  appeared.  Did  its  invasion  mark  the  period 
when  one  of  the  exanthematous  patches  began  to  ulcerate  \ Nearly  at  the 
same  time  supervened  the  peritonitis,  the  cause  of  which  was  discovered  to  be 
the  intestinal  ulceration,  which,  by  extending  in  depth,  had  occasioned  the  per- 
foration of  the  parietes  of  the  ileum. 

Thus  in  this  case,  to  explain  the  group  of  symptoms  observed  during  life, 
before  the  attack  of  the  peritonitis,  there  is  found  a disease  of  the  follicles  ; they 
are  swollen  without  being  red,  and  one  of  the  patches  which  they  constitute  by 
their  union  is  already  ulcerated.  We  shall  not  find  more  intense  lesions  in 
other  cases,  which  shall,  however,  present  to  us  symptoms  of  a much  severer 
nature.  On  the  other  hand,  we  have  already  seen  in  the  former  observations, 
an  instance  wherein  the  symptoms  are  almost  similar  to  those  presented  by  the 
subject  of  the  present  case,  and  in  which,  to  explain  these  symptoms,  which 
were  those  of  a rather  slight  bilious  fever,  we  still  found  the  same  lesion  of 
the  intestinal  follicles.  It  is  not  then  in  typhoid  fevers  alone  that  this  lesion 
exists. 

We  should  note,  in  this  case,  the  coincidence  of  the  healthy  state  of  the  sto- 
mach with  a red  colour  of  the  tongue  ; and  we  should  recollect  that,  at  least  in 
this  individual,  the  vomiting  which  was  excited  had  not  the  effect  of  replacing 
the  signs  of  gastric  derangement  by  those  of  a more  intense  gastritis.  After  the 
vomit  the  tongue  assumed  a natural  appearance,  and  it  was  only  at  a subsequent 
period  it  became  red,  at  the  time  when  the  diarrhoea  appeared. 

The  existence  of  some  tubercles  in  the  summit  of  the  lung  is  worthy  of  being 


DISEASES  OF  THE  ABDOMEN. 


35 


remarked  in  an  individual,  who,  being  attentively  examined  during  the  entiie 
course  of  the  disease,  presented  no  symptom  which  could  induce  us  to  suspect 
such  a lesion  ; he  had  considerable  flesh,  his  breathing  appeared  free,  and  he  had 
no  cough. 

Case  10.  — New  arrival  at  Paris  — Symptoms  of  slight  bilious  fever  — No  improvement  after 
a vomit — Epistaxis  followed  by  a sensible  improvement — Hope  of  approaching  conva- 
lescence; sudden  death  on  the  fourteenth  day  — Some  ulcerations  towards  the  termination 
of  the  small  intestine  — Pulmonary  tubercles. 

A tailor,  nineteen  years  of  age,  residing  in  Paris  for  the  last  six  weeks,  felt  on 
December  the  8th,  without  any  known  cause,  a violent  shivering,  followed  by 
great  heat,  without  sweat.  On  the  following  days  he  felt  continued  heat,  some 
headach,  great  physical  and  mental  dejection  ; distaste  for  all  food,  and  no  alvine 
evacuation.  Having  entered  the  Charite  on  the  25th,  he  presented  all  the 
characters  of  what  is  called  bilious  fever.  (Two  grains  of  tartar  emetic  were 
given.)  The  patient  did  not  vomit,  and  went  several  times  to  stool.  In  the 
night  he  sweated  profusely.  However,  on  the  26th,  the  fever  still  continued ; 
the  tongue  was  red.  Up  to  the  31st,  the  state  of  the  patient  remained  nearly 
the  same.  He  had  some  diarrhoea  ; sweated  every  night;  he  only  took  some 
demulcent  ptisans.  On  the  night  of  the  30th  (the  fourteenth  day),  he  had  pro- 
fuse epistaxis,  and  at  the  same  time  all  the  other  symptoms  improved.  This 
hemorrhage  might  be  reasonably  considered  as  critical.  In  the  course  of  the 
day  the  patient  found  himself  tolerably  well ; the  fever  was  very  moderate. 
Towards  noon  he  arose  from  bed  to  go  to  the  night-chair;  he  had  scarcely 
returned  to  the  bed,  when  he  expired. 

Post-mortem.  The  body,  when  opened  on  the  next  day,  presented  no 
lesion  which  could  account  for  so  sudden  a death.  The  lungs  merely  pre- 
sented some  very  slight  engorgement  posteriorly  ; the  summit  of  the  right 
lung  contained  five  or  six  large  crude  tubercles,  without  hepatisation  around 
them. 

The  inner  surface  of  the  stomach  was  of  a white  colour,  with  a slight  rose 
tint.  To  the  extent  of  some  fingers’  breadth  above  the  caecum,  the  mucous 
membrane  of  the  small  intestine  presented  seven  or  eight  small  ulcerations, 
with  slight  redness  around  them  ; the  caecum  was  red. 

This  is  the  third  case  in  which  we  ascertain  the  state  of  the  digestive  tube  in 
an  individual  who  presented  nothing  but  symptoms  of  slight  continued  fever 
(the  bilious  inflammatory  fever  of  authors),  without  any  complication,  adyna- 
mic or  ataxic.  Here,  then,  are  three  cases,  where  the  symptoms  of  this  fever 
coincide  with  one  and  the  same  species  of  intestinal  lesion,  a lesion  which  is 
only,  in  these  three  cases,  in  different  degrees  : it  is  simple  exantheme,  in  the 
subject  of  the  first  case,  who  died  on  the  sixth  day ; it  is  an  exantheme  with 
commencing  ulceration,  in  the  subject  of  the  ninth  case,  who  died  on  the  third 
day.  In  the  subject  of  the  present  case,  who  died  on  the  14th  or  1 5th  day,  we 
find  merely  ulcerations.  But  what  is  more  remarkable  in  this  latter  case  is,  that 
notwithstanding  the  presence  of  the  ulcerations,  there  was  since  the  last  two 
days  a perceptible  tendency  to  improvement.  As  in  the  subject  of  the  ninth 
case,  the  stomach  was  healthy.  As  in  that  case,  a vomit  was  given ; but  this 
treatment  produced  here  no  good  result'. 

What  now  was  the  cause  of  the  sudden  unforeseen  death  of  this  patient?  — 
Anatomy  was  unable  to  solve  the  question. 

Among  the  cases  of  sudden  death,  which  cannot  be  explained  by  any  appre- 
ciable lesion,  the  following  appears  to  us  one  of  the  most  remarkable. 

boy,  from  four  to  five  years  of  age,  entered  the  Hopital  des  Enfans, 
having  tinea  capitis  for  some  months  ; he  was  attacked  with  pulmonary  catarrh 


36 


ANDItAL’S  MEDICAL  CLINIC. 


and  diarrhoea.  This  twofold  attack  yielded  in  a little  time  to  demulcent  treat- 
ment. 

The  child  had  still  a little  cough,  but  the  purging  had  entirely  ceased  ; he  got 
out  of  bed  and  walked  about  every  day.  On  the  23d  of  August  he  was  sprightly 
as  usual,  got  up,  went  to  the  night  chair,  then  went  to  sit  down,  saying  that  he 
was  disposed  to  sleep.  It  was  imagined  that  he  really  was  asleep.  Seven 
or  eight  minutes  after  he  died. 

No  appreciable  lesion  was  found  in  the  brain  or  its  appendages  ; lungs  healthy, 
as  also  the  heart  and  large  vessels.  The  inner  surface  of  the  stomach  presented 
a white  colour,  with  a slight  rose  tint,  and  some  red  spots  here  and  there  ; the 
rest  of  the  digestive  canal  was  in  general  white,  injected  at  intervals ; the  other 
organs  were  healthy. 

Does  the  heart,  in  cases  of  this  kind,  cease  to  beat  all  at  once?  Is  not  death 
then  a prolonged  syncope  ? Are  the  functions  of  the  brain  suspended  primarily 
and  all  at  once  ? Thus  individuals  die  instantaneously,  who  have  received  a 
violent  electric  shock  ; animals  who  have  been  poisoned  with  hydrocyanic 
acid,  &c. 

Be  this  as  it  may,  observations  of  this  kind  should  make  us  very  circumspect 
in  pronouncing  whether  such  a lesion  observed  in  a dead  body  should  be  really 
considered  as  the  cause  of  the  disease,  and  of  death.  On  the  other  hand,  the 
opening  of  bodies  sometimes  discovers  in  the  organs  most  important  to  life, 
considerable  alterations  not  announced  by  any  symptom.  How  difficult  is  the 
attempt  of  that  person  who  seeks  to  raise  a corner  of  the  veil  with  which  nature 
envelopes  her  works,  whether  she  tends  to  create,  to  preserve,  or  to  destroy  ! 
Homunciones  nos ! observata  colligimus  legesque  condimus  ex  iisdem,  dum 
interim  nos  ssepe  in  observatis  vel  unicum  lateat,  ex  quo  vera  rerum  dependeat 
notifies.  (De  Haen.) 

Let  us  now  carry  our  attention  to  the  pulmonary  phthisis,  of  which  the  patient 
carried  the  germ,  and  which  had  not  yet  revealed  its  existence  by  any  species  of 
symptom.  The  tubercles  contained  in  the  summit  of  the  left  lung  might  have 
remained  stationary  for  a length  of  years,  and  not  have  prevented  the  individual 
from  attaining  the  mean  duration  of  life  ; but  in  persons  so  circumstanced,  the 
slightest  irritation  directed  to  the  lungs  is  attended  with  the  worst  consequences  ; 
it  contributes  very  much  to  augment  the  tubercular  diathesis,  and  to  hasten  the 
softening  of  the  tubercles  already  existing.  Such  is  the  first  stage  of  the  phthisis 
of  Bayle.  The  autopsy  discovers  it  in  individuals  who  have  scarcely  had  a slight 
cold  during  life.  It  is  principally  from  these  facts  that  Bayle  has  maintained  that 
pulmonary  tubercles  were  not  a product  of  inflammation,  in  the  sense  ordinarily 
attached  to  this  term.  Those  who  maintain  the  contrary  doctrine  are  obliged  to 
admit  a disposition  peculiar  to  tuberculisation  in  the  individuals  in  whom  the 
development  of  the  tubercles  has  succeeded  to  an  inflammation  of  the  bronchi,  or 
of  the  tissue  of  the  lung.  But  does  not  this  sort  of  idiosyncrasy  resemble  very 
strongly  the  innate  germ  of  phthisis,  which  Bayle  admitted,  and  for  which  he  has 
been  so  severely  reproached  ? 

Case  11. — Disturbance  of  the  intellect  without  any  other  serious  symptom — Tongue  dry 

from  time  to  time — Strength  still  retained — Unexpected  death — Ulcerations  in  the  small 

intestine. 

A German,  fifty-six  years  old,  entered  the  hospital  on  the  29th  of  November. 
He  could  give  no  account  of  his  previous  state.  He  seemed  absorbed  in  religious 
feelings.  Countenance  pale  and  meagre  ; strength  seemed  well  preserved ; tongue 
dry  and  pale.  He  went  to  stool  as  in  health.  Skin  hot;  pulse  frequent  and 
hard  ; breathing  natural ; chest,  when  percussed,  sounded  well. 

The  marked  stupor  of  this  patient’s  intellects,  the  species  of  ecstasy  in  which 
he  was,  might  be  considered  as  the  prelude  to  ataxic  fever.  The  indication 


DISEASES  OF  THE  ABDOMEN.  37 

seemed  to  be  to  unload  the  brain.  (Twenty  leeches  to  the  anus  ; barley  ptisan  ; 
emollient  lavement.) 

On  the  next  day,  his  state  not  altered.  The  following  days  the  fever  still 
continued  ; intellectual  faculties  nearly  abolished  ; tongue  pale,  and  alternately 
moist  and  dry  ; strength  still  preserved.  On  the  8th  of  December,  the  state  of 
ecstasy  more  marked  than  ever  ; answers  slow  and  confused.  (Bleeding  to  two 
palettes.)  No  good  result  from  it:  his  state  even  worse  than  the  day  before. 
Tongue  brown  ; had  some  transitory  delirium  and  considerable  fever ; coughed  a 
little.  The  continuance  of  the  strength  of  the  pulse  appeared  to  be  connected 
with  hypertrophy  of  the  left  ventricle.  The  stethoscope,  in  fact,  when  applied 
to  the  precordial  region,  was  a little  repelled ; with  the  hand  nothing  unnatural 
could  be  discovered  in  the  pulsations  of  the  heart.  Still  the  patient  was  even 
now  able  to  sit  up;  he  ate  two  small  biscuits  with  an  appetite;  his  state  re- 
maii^d  unaltered  during  the  day,  and  to  our  great  surprise  he  died  that  night. 

Post-mortem , twenty-eight  hours  after  death.  The  subarachnoid  cellular  tissue 
was  infiltrated  with  a considerable  quantity  of  limpid  colourless  serum.  The 
parietes  of  the  left  ventricle  were,  as  we  anticipated,  very  much  hypertrophied, 
and  its  cavity  diminished.  Old  cellular  adhesions  were  found  in  the  two  pleurae. 
The  base  of  the  right  lung  was  of  a greyish  red  colour,  its  tissue,  which  did  not 
crepitate,  was  reduced  to  a pulp  beneath  the  finger;  every  where  else,  the  lungs 
crepitated  very  well ; an  enormous  quantity  of  frothy  colourless  serum  flowed 
from  them  on  making  an  incision  into  them. 

The  stomach  was  dilated ; its  inner  surface  presented,  at  the  great  cul-de-sac, 
and  along  the  anterior  surface,  to  nearly  as  far  as  the  pylorus,  a brown  colour, 
with  a mixture  of  small  black  spots ; this  colour  and  these  spots  existed  in  the 
softened  mucous  membrane.  The  inner  surface  of  the  small  intestine  was  very 
white  to  near  the  caecum  ; it  was,  however,  very  much  narrowed  in  all  its  extent. 
At  five  fingers’  breadth  above  the  caecum  there  was  an  ulcer  of  considerable 
breadth,  the  bottom  of  which  was  formed  by  the  muscular  membrane  laid  bare, 
and  the  edges  were  formed  by  the  mucous  membrane,  which  was  tumefied,  soft, 
and  black  ; this  membrane  presented  the  same  appearance  as  far  as  the  caecum, 
the  mucous  membrane  of  which  was  white ; the  rest  of  the  large  intestine  was 
healthy. 

In  this  patient  we  find  nearly  the  same  lesions  of  the  digestive  tube  as  the 
preceding;  and  yet  what  a difference  in  the  symptoms  ! In  this  case  also  death 
was  unexpected.  On  examining  the  state  of  the  different  functions,  considering 
more  particularly  the  circumstance  of  the  strength  being  still  retained,  could  one 
anticipate  that  a few  hours  after  the  visit,  the  patient  would  have  died  without 
any  new  phenomenon  developing  itself?  Can  we  seek  the  cause  of  this  in  the 
very  extensive  oedema  of  which  the  lungs  were  the  seat  ? Can  we  suppose  that 
during  the  night  of  the  10th  of  December,  the  lungs  became  suddenly  engorged 
with  serum,  in  the  same  manner  as  we  see  serous  accumulations  take  place, 
sometimes  almost  instantaneously  in  other  parts  of  the  body  ? Is  it  rather  in 
the  organic  state  of  the  heart  we  should  place  the  cause  of  death  ? We  know 
sudden  death  is  by  no  means  an  uncommon  occurrence  in  individuals  affected 
with  aneurisms  of  the  heart,  though  even  but  little  advanced,  and  which  do  not 
as  yet  manifest  their  existence  by  any  well-marked  symptom.  It  seems  that  in 
several  of  these  patients  the  heart  momentarily  loses  the  power  of  contracting ; 
after  that  the  blood  no  longer  reaches  the  brain,  the  breathing  becomes  sus- 
pended; and  if  this  cessation  of  the  heart’s  action  is  continued,  the  syncope 
changes  into  real  death.  We  may  remark  that  none  of  these  circumstances 
existed  in  the  preceding  patient,  whose  death  came  on  even  still  more  unex- 
pectedly. 

Was  the  peculiar  state  of  the  intellectual  faculties  a sympathetic  phenomenon 
connected  with  the  inflammation  of  which  the  stomach  and  the  termination  of 
4 


38 


ANDRAL’S  MEDICAL  CLINIC. 


the  small  intestine  were  the  seat?  Did  the  entire  disease  exist  in  the  digestive 
tube  ? 

The  inflammation  of  the  right  lung  existed  for  some  days  at  least,  as  was 
proved  by  the  state  of  the  organ  ; but  could  it  even  be  suspected?  Occupying 
only  the  base  of  the  lung,  it  eould  not  be  recognised  either  by  percussion  or 
auscultation ; the  breathing  was  perfectly  free,  the  sputa  were  absent,  and  as  to 
the  very  slight  cough  which  existed,  should  it  not  reasonably  be  referred  solely 
to  inflammation  of  the  bronchi? 

The  character  of  the  pulse,  in  this  patient,  likewise  merits  all  our  attention. 
How  insufficient  are  the  signs  derived  from  the  arterial  pulsations,  when  we 
have  not  at  the  same  time  regard  to  the  state  of  the  heart ! 

Case  12.— Previous  mental  and  bodily  distress — Remittent  fever  combatted  by  quinquina — 
Disappearance  of  the  daily  shivering;  continuation  of  the  same  medicine;  ataxo-adynamic 
symptoms — Death  towards  the  25th  day— Change  of  the  follicular  patches  into  a hard  mass 
like  an  eschar — Milky  infiltration  of  the  cerebral  membranes — Brain  dotted — Softening  of 
the  lungs. 

A carpenter,  twenty-six  years  of  age,  of  a strong  make,  living  in  a moist 
situation,  experienced  some  mental  distress  and  considerable  bodily  fatigue  at 
the  commencement  of  the  year  1820.  Towards  the  15th  of  October  of  the  same 
year,  he  was  seized  with  spontaneous  lassitude,  pains  in  the  kidneys  and  limbs; 
lie  lost  all  appetite.  These  symptoms  continued  on  the  following  days.  He 
had  a regular  shivering  fit  every  day  towards  two  o’clock  at  noon,  which  was 
replaced  by  an  intense  heat,  not  followed  by  any  sweat.  This  man  consulted 
several  medical  men  who  made  him  take  a vomit  and  two  purgatives ; he  then 
drank  a bitter  ptisan.  He  had  profuse  diarrhoea  from  the  day  he  took  the 
vomit.  He  entered  the  Charite  on  the  1st  of  November,  when  two  palettes  of 
blood  were  taken  from  him,  and  twenty  leeches  applied  to  the  anus. 

On  the  2d  of  November,  the  blood  drawn  the  preceding  day  was  covered 
with  a buflfy  coat  of  little  consistence;  the  patient  presented  the  following  state; 
— general  lassitude,  sleeplessness,  tinnitis  aurium,  nostrils  dry,  mouth  bitter, 
tongue  yellowish,  having  a tendency  to  become  dry  without  any  redness ; little 
thirst,  anorexia,  abdomen  soft,  a little  painful  on  pressure  ; five  very  liquid  stools ; 
breathing  full  and  easy  ; speech  short ; pulse  full  and  frequent ; skin  a little  moist. 
The  daily  shiverings  indicated  the  presence  of  remittent  fever,  which  was  com- 
batted by  a watery  infusion  of  quinquina  sweetened  with  syrup  of  quince. 
(Barley  water ; sinapisms  to  the  legs.) 

Shivering  entirely  absent.  On  the  next  morning  there  was  a sensible  im- 
provement ; the  patient  had  some  sleep ; tongue  moist ; pulse  less  frequent ; 
gentle  heat  of  the  skin;  abdomen  soft  and  free  from  pain,  continuance  of  the 
diarrhma.  (Same  prescription.) 

This  improvement  was  but  transient,  and  on  the  4th,  the  most  alarming  symp- 
toms existed.  An  air  of  stupor;  extreme  prostration  of  strength;  tongue  dry 
and  black  ; great  thirst;  abdomen  free  from  pain  ; two  stools  only ; pulse  very 
frequent.  (Two  blisters  to  the  legs,  frictions  with  camphorated  alcohol  on  the 
extremities  ; the  same  drinks,  and  some  mineral  lemonade,  and  a little  wine.) 

In  the  afternoon  the  patient  commenced  to  rave ; his  ideas  were  very  incoherent 
for  the  entire  night.  On  the  morning  of  the  5th,  the  delirium  continued  ; the 
other  symptoms  had  not  changed.  (Four  leeches  were  applied  behind  each  ear, 
and  two  blisters  were  placed  on  the  thighs.) 

On  the  6th,  the  same  state.  (Eight  leeches  more  to  the  neck.) 

On  the  7th,  less  delirium,  but  extreme  dejection  ; features  entirely  decomposed ; 
sensation  of  acute  pain  in  the  loins  ; burning  thirst ; tongue  black  ; abdomen  tym- 
panitic and  free  from  pain ; five  or  six  liquid  stools  passed  in  bed  ; skin  dry  and 
hot ; pulse  very  frequent,  and  possessing  considerable  resistance.  (More  leeches 
to  the  neck.) 


DISEASES  OF  THE  ABDOMEN. 


S9 

On  the  8th,  the  countenance  indicated  the  most  extreme  dejection  ; breathing 
very  much  accelerated:  tongue  clammy,  less  dry  than  on  the  preceding  days  ; 
abdomen  tympanitic  -r  intellect  quite  gone. 

He  died  on  the  9th,  at  five  o’clock  in  the  morning. 

Post-mortem , thirty  hours  after  death.  Cranium.  — A turbid  milky  serum 
existed  in  small  quantity  in  the  subarachnoid  cellular  tissue  of  the  upper  surface 
of  the  two  cerebral  hemispheres.  The  cerebral  substance,  of  ordinary  consist- 
ence, was  dotted  with  red  points  ; black  liquid  blood  distended  the  sinuses  of  the 
dura  mater  ; a small  spoonful  of  limpid  serum  existed  in  each  of  the  lateral  ven- 
tricles. 

Thorax.  — Heart  proportioned  to  the  size  of  the  individual  and  to  the  deve- 
lopment of  the  muscular  system.  The  two  lungs  were  of  a livid  red  colour  pos- 
teriorly and  at  their  base  ; they  were  engorged  with  an  enormous  quantity  of 
reddish  serum  ; their  tissue  crepitated,  but  was  extremely  soft ; it  was  reduced 
to  a sort  of  a pulp  under  pressure  of  the  finger. 

Abdomen.  — The  stomach  was  moderately  distended  with  a brownish  liquid 
and  with  gases  ; its  inner  surface  was  of  a greyish  white  colour  in  all  its  extent, 
except  along  the  small  curvature,  where  we  observed  two  or  three  red  bands, 
which,  without  assuming  a regular  form,  were  continued  from  the  cardia  to  the 
pyloric  extremity.  On  placing  this  part  of  the  stomach  between  the  light  and 
the  eye,  there  was  distinctly  perceived  a number  of  vessels,  which  were  ramified, 
and  between  them  several  small  reddish  points,  which  appeared  to  be  formed  of 
effused  blood. 

The  small  and  large  intestine,  when  examined  internally,  presented  a great 
number  of  patches  of  a bright  red  colour,  presenting,  on  an  average,  about  two  or 
three  fingers’  breadth  in  length,  and  one,  or  at  most  two,  in  breadth.  These 
patches  were  formed  of  ramified  vessels,  around  which  there  existed  some  red 
points ; they  were  seated  in  the  cellular  tissue  which  united  the  peritoneal  to 
the  muscular  membrane  ; the  corresponding  portion  of  mucous  membrane  was 
not  changed. 

The  small  intestine,  when  examined  internally,  was  healthy  along  the  upper 
four-fifths.  The  lower  fifth,  hard  and  bosselated  (bossele)  externally,  presented 
internally  numerous  elevations,  of  an  oval  or  irregularly  circular  form,  covered 
with  a sort  of  detritus  of  a yellowish  grey  colour,  which  was  raised  by  scraping 
with  the  scalpel.  Beneath  this  detritus  there  was  found  a hard  tissue  of  a violet 
red  colour,  appearing  to  be  formed  of  submucous  cellular  tissue  considerably 
thickened.  Of  these  elevations  the  most  extensive  were  from  three  to  four 
inches  in  diameter  in  every  direction  ; the  smallest  were  scarcely  from  two  to 
three  lines.  In  the  intervals  between  them  the  mucous  membrane  was  very 
much  injected.  Near  the  ileo-caecal  valve,  and  even  on  this  valve,  they  were  so 
close  that  they  formed  but  one  single  bosselated  and  wrinkled  mass,  of  a yellow- 
ish grey  colour.  This  alteration  terminated  abruptly  at  the  entrance  of  the 
caecum.  The  inner  surface  of  this  latter  intestine  was  very  red,  as  also  that  of 
the  ascending  colon.  These  two  intestines  were  filled  with  a reddish  and  as  it 
were  bloody  mucus;  the  mucous  membrane  of  the  rest  of  the  large  intestine  was 
very  white. 

The  alteration  of  the  intestinal  follicles  in  this  case  differs  from  that  presented 
to  us  in  the  preceding  cases  ; it  is  no  longer  simple  tumefaction  of  the  glands 
(plaques)  that  is  observed,  it  is  their  change  into  eschars.  Had  the  individual 
lived  longer,  these  eschars  would  have  been  detached,  and  ulcerations  would 
have  replaced  them.  This  is  one  of  the  morbid  forms  which  Peyer’s  glands 
present  before  becoming  ulcerated  ; the  cure  could  not  be  effected,  without  their 
ulceration  had  previously  taken  place.  Here  the  follicular  layer  is  no  longer 
distinct : in  its  place  we  find  merely  a hard,  yellowish  mass,  removeable  by 
the  scalpel,  as  a sort  of  detritus.  In  the  following  observations  we  shall  see  this 


40 


ANDRAL’S  MEDICAL  CLINIC. 


layer,  already  so  altered,  assume  still  further  ail  the  characters  of  a true  eschar, 
become  separated  in  shreds  from  the  subjacent  tissues,  and  leave  in  their  place 
ulcerations  of  variable  size.  This  ease  then  presents  to  us  an  instance  of  the 
transition  from  the  first  to  the  second  stage  of  dothinenteritis  : there  is  no  doubt, 
if  the  individual  had  lived  longer,  but  that  ulcerations  would  have  been  found  in 
his  intestine. 

If  we  now  inquire  what  were  the  symptoms  which  coincided  with  this  state  of 
the  intestine,  we  shall  find  that  these  symptoms  are  similar  to  those  already  pre- 
sented to  us  by  other  individuals,  in  whom  the  dothinenteritis  had  not  gone  beyond 
the  first  stage. 

With  respect  to  the  symptoms,  the  disease  which  forms  the  subject  of  this 
case  presents  three  stages  to  be  considered.  In  the  first  we  see  nothing  but  those 
general  symptoms,  which  precede  most  local  diseases,  pneumonia  as  well  as 
enteritis,  but  which,  however,  are  more  frequently  the  precursors  of  gastrointes- 
tinal inflammations.  The  second  stage  is  marked  by  the  existence  of  a remittent 
fever,  which  becomes  a simple  continued  feverafter  the  exhibition  of  quinquina. 
These  accessions,  which  thus  returned  every  day,  but  which,  commencing  with 
shivering,  never  terminated  by  a sweat,  were  they  connected  with  the  intestinal 
exantheme  ? Were  they  but  an  additional  phenomenon  ? We  shall  not  decide 
these  questions  ; but  with  respect  to  treatment,  we  shall  observe  that  if  the  quin- 
quina prevented  the  return  of  the  shivering,  and  if  it  thus  had  a marked  anti- 
periodical action  ; if  even  the  day  after  it  was  given  for  the  first  time,  there  was 
a perceptible  improvement ; ifin  particular,  we  found  the  tongue  moist,  its  continual 
administration  on  the  following  days  was  followed  by  considerable  prostration, 
and  most  serious  nervous  symptoms,  which  were  not  removed  by  leeches  applied 
to  the  neck  and  behind  the  ears.  These  nervous  symptoms  were  connected,  in 
this  particular  case,  with  a morbid  state  of  the  meninges.  As  in  other  cases 
already  cited,  we  found  the  gastric  mucous  membrane  injected  and  dotted,  in  a 
person  who  for  several  days  had  taken  different  stimulating  drinks,  quinquina, 
wine,  sulphuric  lemonade. 

Case  13.  — Previous  fatigue  — Fever  at  first  remittent  — Bad  effect  of  an  emeto  cathartic  — 
Adynamic  state  becoming  more  and  more  marked  after  bloodletting,  not  diminished  by 
tonics  — Death  towards  the  46th  day  — In  the  small  intestine  follicular  patches  attacked 
with  gangrene  and  ulcerated  — In  the  large  intestine  white  ulcers  without  any  redness 
around  them  — Submucous  sanguineous  effusion  in  the  stomach  — Another  effusion  of 
blood  in  the  pleura  — Liquid  blood  in  the  vessels;  aorta  red  — Spleen  large  and  soft. 

A quarry-man,  twenty-eight  years  of  age,  brown  skin,  black  hair,  muscles  well 
developed,  was  very  much  harassed  with  work  during  the  first  half  of  the  month 
of  July.  Towards  July  the  20th,  he  commenced  to  feel  ill ; intense  headach  ; 
his  appetite  was  lost,  strength  impaired  ; he  was  given  an  emeto-cathartic ; he 
vomited  copiously,  and  went  several  times  to  stool.  From  this  period  he  had 
diarrhoea.  Dating  from  the  commencement  of  August,  he  kept  his  room,  and 
soon  kept  his  bed.  All  the  day  he  experienced  a burning  heat ; at  night  he  felt 
considerable  cold  in  the  feet  and  legs  ; he  sweated  very  much  every  night.  He 
took  no  active  medicine  up  to  August  28th  ; he  then  entered  the  hospital  and 
presented  the  following  stale  : — 

Sub-orbital  headach,  face  red,  eyes  brilliant,  pains  in  the  limbs,  general  debility  ; 
tongue  covered  with  a slight  whitish  coat;  bitter  taste  in  the  mouth;  thirst; 
anorexia  ; abdomen  free  from  pain,  and  soft;  four  or  five  stools  within  the  last 
twenty-four  hours,  preceded  by  slight  colics  : slight  cough  ; sensation  of  heat 
in  the  throat,  deglutition  painful  ; pulse  frequent,  of  ordinary  strength  ; skin  hot, 
and  a little  moist. 

No  precise  indication  presented  itself;  the  symptoms  were  sufficiently  mode- 
rate to  induce  one  to  think  that  they  would  yield  to  simple  diluents,  diet,  and 
repose.  (Rice  water  with  gum.) 


DISEASES  OF  THE  ABDOMEN. 


41 


The  patient  wen-t  but  twice  to  stool,  up  to  the  next  morning.  Partial  cold  in 
the  evening  and  sweat  during  the  night,  as  usual.  At  the  visit  of  the  29th, 
there  was  still  headach,  redness  of  the  face,  and  injection  of  the  conjunctiva; ; 
cough  more  frequent;  pulse  fuller.  Thus  the  state  of  general  erethism  had  in- 
creased. (Bloodletting  to  four  palettes.) 

The  blood  drawn  from  the  vein  united  into  a large  clot,  whch  was  soft 
and  without  the  buffy  coat.  The  febrile  exacerbation  was  very  great  in  the 
evening. 

On  the  30th,  the  redness  of  the  face  had  been  succeeded  by  a remarkable  pale- 
ness ; the  tongue,  divested  of  its  whitish  coat,  presented  a uniform  red  colour  ; 
lips,  teeth,  and  nares  dry;  four  liquid  stools  had  taken  place  ; abdomen  soft; 
pulse  frequent,  and  very  compressible  ; heat  of  skin  not  much  raised.  (Barley 
ptisan  with  gum  ; strict  diet.)  Exacerbation  in  the  evening,  without  the  sen- 
sation of  previous  cold  ; sweats  and  distressing  raving  during  the  night. 

On  the  31st  an  air  of  stupor ; same  state  in  other  respects.  (Two  blisters  to 
the  legs.)  In  the  evening  a slight  disturbance  in  his  ideas. 

September  1st,  air  of  stupor  more  marked  ; patient  had  now  become  very 
deaf ; his  intellect  in  other  respects  sufficiently  clear;  he  had  got  out  of  bed 
thrice  to  go  to  stool.  Tongue  dry  ; abdomen  tympanitic  ; pulse  very  frequent, 
and  compressible.  (Six  leeches  behind  each  ear  ; embrocations  of  camphorated 
oil  of  camomile  to  the  abdomen  ; camomile  lavement  with  the  addition  of  twelve 
grains  of  camphor  ; barley  ptisan.) 

The  leeches  acted  very  well and  on  the  morning  of  the  2d,  several  of  the 
bites  were  still  bleeding  ; the  stupor  went  on  increasing.  The  leaden  cast  of 
the  countenance,  the  dull  expression  of  the  eyes,  which  were  half-covered  by 
the  upper  eyelid,  the  increased  deafness,  the  slowness  and  uncertainty  of  the 
answers,  the  extreme  weakness  of  the  pulse,  which  was  as  it  were  tremulous, 
and  which  beat  above  130  a minute,  the  particular  manner  in  which  the  patient 
lay,  he  always  sliding  down  towards  the  foot  of  the  bed,  announced  the  exist- 
ence of  an  adynamic  state,  which  called  for  urgent  treatment.  The  tongue  was 
at  the  same  time  dry  and  pale,  the  abdomen  tolerably  soft ; he  had  had  but  two 
stools.  Two  more  blisters  were  applied  to  the  thighs  ; those  of  the  legs  were 
dry.  (Infusion  of  quinquina  with  gum,  decoction  of  polygala,  lavement  and 
embrocations  as  on  the  day  before.) 

In  the  evening  the  state  of  the  patient  seemed  to  have  undergone  a slight  im- 
provement ; the  expression  of  the  countenance  was  somewhat  more  animated  ; 
he  lay  of  himself  on  the  right  side  ; the  pulse  was  somewhat  raised  ; three  or 
four  of  the  leech-bites  were  still  bleeding,  notwithstanding  the  efforts  made  to 
stop  them. 

During  the  night  the  patient  was  completely  delirious. 

On  the  3d,  the  tongue  was  moist ; the  teeth  were  covered  with  black  crusts, 
some  lenticular  spots,  of  a livid  tint,  were  scattered  over  the  epigastrium.  (The 
same  drinks  ; lavement  with  an  ounce  of  quinquina  and  twelve  grains  of  cam- 
phor ; liniment  of  ammonia  with  the  addition  of  an  ounce  of  tincture  of  lavender 
to  rub  the  extremities.) 

Up  to  the  following  morning  the  patient  continued  in  a continued  state  of 
coma. 

On  the  4th,  the  countenance  became  cadaverous ; gave  no  answers  to  ques- 
tions ; put  out  his  tongue,  when  asked,  which  was  pale,  moist,  and  slightly  in- 
crusted  at  the  centre.  Lips  and  teeth  black  ; four  involuntary  stools  ; pulse  144. 
Some  wine  was  ordered. 


The  patient  went  on  sinking,  and  died  at  five  o’clock  the  next  morning. 
Post-mortem,  twenty-nine  hours  after  death.  Brain  and  its  membranes  re- 
markably pale  ; ventricles  nearly  empty. 

Thorax . — Heart,  empty  of  blood,  presented  a soft,  flaccid  tissue,  entirely 
4* 


42 


ANDltAL’S  MEDICAL  CLINIC. 


divested  of  colour  ; a great  quantity  of  bloody  serum,  of  a deep  brown  colour, 
engorged  both  lungs.  About  a pint  of  a black  liquid,  presenting  all  the  physi- 
cal properties  of  venous  blood,  was  effused  into  each  pleura,  which  presented 
no  other  trace  of  inflammation. 

Jlbdomen.  — The  stomach,  distended  with  liquids,  presented  externally  in 
that  portion  of  it  which  is  in  contact  with  the  spleen,  a livid  red  tint;  internally, 
it  had  everywhere,  except  in  this  portion,  a greyish  white  tint;  the  mucous 
membrane  was  of  ordinary  thickness,  and  may  be  readily  detached  under  the 
form  of  a membrane.  In  the  splenic  portion  there  existed  four  or  five  large 
red  spots,  owing  to  a sanguineous  infiltration  seated  in  the  submucous  cellular 
tissue,  and  which  had  communicated  its  colour  to  the  membrane  itself. 

The  duodenum,  jejunum,  and  the  upper  third  of  the  ileum  were  pale  and 
contained  a considerable  quantity  of  yellow  bile.  But  in  the  lower  third  of  the 
ileum  there  existed  different  species  of  lesions.  From  the  inner  surface  of  the 
intestine  there  projected  several  patches  of  a more  or  less  deep  red  ; they  were 
raised  one  or  two  lines  above  the  level  of  the  mucous  membrane.  Their  form 
was  irregularly  oval ; the  smallest  equalled  a pea  in  diameter,  and  the  largest 
that  of  a thirty  sous  piece.  They  were  formed  of  thickened  mucous  membrane. 
In  the  intervals  this  membrane  was  but  slightly  injected.  Several  of  these  pre- 
sented in  some  points  of  their  surface  ulcerations,  the  bottom  of  which  was 
formed  of  laminated  tissue.  Others  were  partly  transformed  into  a yellowish 
tissue,  altogether  similar  to  an  eschar  in  all  its  physical  properties.  Others 
were  entirely  changed  into  this  same  tissue  ; the  colour  was  not  removed  by 
repeated  washing ; it  was  necessary  to  tear  it  in  order  to  separate  it  from  the 
subjacent  tissues  ; and  it  eould  not  be  confounded  with  faecal  matter.  In  other 
parts  these  eschars  were  partly  removed,  and  thence  resulted  eschars  of  a more 
or  less  irregular  form,  the  bottom  of  which  consisted  of  the  laminated  tissue 
which  had  remained  healthy.  In  one  or  two  ulcerations,  the  eschar,  which  had 
been  almost  detached,  was  held  on  only  by  a very  thin  pedicle.  In  fine,  other 
ulcerations  no  longer  presented  any  trace  of  them  ; a large  eschar  covered  the 
upper  surface  of  the  ileo-caecal  valve. 

The  mucous  membrane  of  the  caecum  and  of  the  three  portions  of  the  colon 
presented  a considerable  number  of  small  rounded  superficial  ulcers,  the  edges 
and  bottom  of  which  were  white  ; they  seemed  progressing  towards  cicatrisa- 
tion ; the  mucous  membrane  was  pale  in  the  intervals  between  them. 

The  spleen  was  very  large ; the  aorta  contained  a small  quantity  of  black 
liquid  blood  ; its  inner  membrane  was  of  a uniform  red  colour. 

In  this  case  the  different  stages,  and  the  formation  of  intestinal  ulcers  may 
be  very  clearly  traced.  We  find  at  one  and  the  same  time  in  the  small  intes- 
tine, 1st,  follicular  patches  simply  tumefied  ; 2dly,  these  same  patches  trans- 
formed into  a grey,  brown,  or  yellow  tissue,  resembling  eschars  ; 3dly,  these 
eschars  themselves  partly  detached  ; and  held  down  to  the  subjacent  tissues 
only  by  their  shreds,  etc.  ; 4thly,  in  their  stead,  in  fine,  ulcerations,  at  the  bot- 
tom of  which  cellular  tissue  exists,  healthy  or  diseased.  In  the  large  intestine 
it  is  still  ulcerations  which  are  met;  but  no  trace  of  exantheme  is  found  ; the 
ulcerations  themselves  have  a peculiar  appearance  : they  are  white  at  their 
edges,  as  at  their  bottom.  This  latter  is  formed  of  cellular  tissue  in  a perfectly 
healthy  state ; the  membrane  surrounding  them  is  equally  devoid  of  colour.  It 
is  evident  that  in  this  large  intestine  there  existed  at  a period  considerably  re- 
mote from  that  of  death,  a morbid  process  which  became  less  and  less  active, 
and  that  the  ulcerations  discovered  there  tended  to  cicatrise.  Remark  also  that 
the  profuse  diarrhoea  which  the  patient  experienced  at  the  commencement,  and 
which  followed  the  emeto-cathartic  given  at  this  period,  diminished  progres- 
sively, and  that  it  was  but  very  slight  two  days  before  death. 

There  is  another  very  remarkable  circumstance  in  this  case.  Let  us  recol- 
lect the  mildness  of  the  symptoms  presented  by  the  patient  on  the  28th  ot 


DISEASES  OF  THE  ABDOMEN. 


43 


August;  let  us  recollect  all  the  symptoms  of  reaction  presented  on  the  day  after; 
to  meet  these,  did  not  bloodletting  seem  to  be  indicated  ? Yet  scarcely  sixteen 
ounces  of  blood  were  taken  from  a vein  in  the  arm,  when  all  at  once  the  tongue 
became  red  and  dry,  the  patient  fell  into  a decidedly  adynamic  state,  and  one 
which  appeared  real,  if  we  are  to  judge  from  the  aggregate  of  the  phenomena 
which  presented  themselves.  After  the  application  of  blisters  to  the  legs,  the 
prostration  increased ; it  became  extreme  after  more  blood  was  abstracted  by 
leeches,  the  bites  of  which  bled  very  profusely.  We  should  also  remark  as 
one  of  the  consequences  of  the  general  state,  the  extreme  difficulty  experienced 
in  endeavouring  to  arrest  the  bleeding  from  some  of  these  bites.  Recourse 
was  then  had  to  tonic  mixtures,  and  tonic  lavements ; no  benefit  resulted  from 
them. 

In  this  case  were  the  bleedings  merely  of  no  use  ? Were  they  not  directly 
injurious  ? One  would  be  inclined  to  think  so,  on  reflecting  with  what  rapidity, 
after  the  bleeding,  a very  unfavourable  state  succeeded  a combination  of  symp- 
toms which  presented  nothing  alarming.  Shall  we  admit  that,  in  this  individual, 
who  was  apparently  very  strong,  the  excessive  fatigue  experienced  during  the 
great  heats  of  July  had  so  exhausted  the  innervation  that  the  sudden  abstraction 
of  a certain  quantity  of  blood  readily  and  easily  produced  an  adynamic  state  ? 
Shall  we  admit  that  this  state  of  exhaustion  of  the  innervation,  which,  at  the 
same  time  that  it  showed  itself  externally  by  special  symptoms,  occasioned  also 
the  mode  of  termination  of  the  intestinal  affection,  produced  also  the  gangrene 
and  ulceration  of  the  follicular  patches  ? Thus  let  a slight  redness  develope  itself 
in  any  point  whatever  of  the  skin,  it  will  terminate  promptly  in  resolution,  if 
the  patient’s  strength  is  still  good  ; on  the  contrary,  it  will  terminate  in  gangrene 
and  ulceration,  if  the  patient  be  in  a state  of  greater  or  less  debility.  No  doubt, 
in  thus  explaining  the  unfavourable  symptoms  which  manifested  themselves  in 
this  individual  after  the  bleedings,  we  merely  lay  down  an  hypothesis  ; but  is 
it  not  one  of  the  most  probable  which  can  be  proposed  ? Has  it  not  in  its  sup- 
port a greater  number  of  other  cases  wherein  ataxo-adynamic  symptoms  were 
also  seen  to  follow  so  closely  on  bloodletting,  that  one  might  reasonably  conclude 
that  these  symptoms  had  been  at  least  favoured  in  their  development  by  loss  of 
blood,  whether  too  profuse,  or  ill-timed  ? Besides,  is  it  not  also  an  hypothesis 
to  admit,  in  order  to  account  for  the  phenomena,  that  immediately  after  the  first 
bloodletting,  the  intestinal  inflammation  was  so  much  aggravated  as  to  change  a 
disease  hitherto  mild,  into  a most  serious  affection  ? If  this  exasperation  of  the 
symptoms  after  bleeding  had  been  observed  only  once,  such  an  explanation  might 
no  doubt  be  adopted ; but  if  bloodletting  has  been  observed  to  be  followed  by 
such  phenomena  a great  many  times,  would  it  not  be  extraordinary  to  suppose 
that  a means  which  is  usually  considered  to  remove,  or  at  least  moderate,  in- 
flammation in  general,  has  on  the  contrary  produced  an  increase  of  the  intes- 
tinal inflammation  ? If  this  supposition  be  objected  to,  and  if,  on  the  other  hand, 
it  be  no  less  objectionable  to  think  that  two  phenomena  so  often  seen  to  succeed 
each  other,  presented  themselves  together  only  by  mere  accident,  there  will 
now  remain  but  two  hypotheses  : 1st,  it  will  be  admitted  that  intestinal  inflam- 
mation is  of  a nature  altogether  specific,  and  that  bloodletting  does  not  suit  it; 
but  this  hypothesis  will  be  soon  overturned  ; for  how  often  have  we  seen  the 
symptoms  of  this  inflammation  moderated  after  bloodletting?  2dly,  it  will  be  said 
with  us,  that  bloodletting  is  injurious  in  a certain  number  of  cases,  where  the 
innervation  is  in  such  a state,  that  everything  which  tends  to  deprive  the  ner- 
vous centres  of  energy,  tends  also  to  destroy  life,  by  producing  those  different 
disturbances  of  innervation  which  are  called  ataxic  or  adynamic  symptoms,  at 
the  same  time  that  sanguineous  congestion  is  seen  to  progress  towards  gangrene 
or  towards  ulceration. 

In  the  case  which  furnished  to  us  these  reflections,  we  shall  not  lose  sight  of 
some  remarkable  alterations  observed  principally  in  cases  where,  whether  pri- 


44 


ANDItAL’S  MEDICAL  CLINIC. 


raarily  or  after  the  absorption  of  miasms,  the  innervation  has  been  seriously  in- 
fluenced. Let  us  consider  those  ecchymoses  of  the  stomach,  those  effusions 
of  blood  into  the  pleura,  those  petechiae  some  days  before  death  ; does  not  this 
also  exist  in  the  typhus  of  Europe,  whether  by  infection  or  contagion,  in  the 
yellow  fever,  and  in  scurvy  ? Is  not  this  also  observed  in  several  cases  of  small- 
pox, in  which  it  is  also  very  difficult  to  account  for  the  symptoms  and  for  death 
solely  by  the  lesions  discovered  on  the  body  after  death  ? Such,  for  instance, 
is  the  following  case  : — 

A girl,  fourteen  years  of  age,  was  attacked  with  discrete  small-pox,  which  went 
on  without  any  thing  particular  occurring  for  the  first  seven  days,  dating  from  the 
time  of  the  eruption.  Then  the  pustules,  full  of  an  opaque  white  matter,  began 
all  at  once  to  become  flaccid  and  depressed.  At  the  same  time  there  was  sudden 
emaciation  of  the  face,  the  eyes  dull ; extreme  prostration  of  strength ; inex- 
tinguishable thirst ; appearance  of  the  tongue  natural ; purging;  frequent  pulse ; 
skin  hot  and  dry.  These  symptoms  continued  during  three  days;  the  debility 
increased,  and  the  patient  died. 

Post-mortem.  State  of  the  Skin. — The  pustules  presented  themselves  under 
three  different  forms.  Most  of  them  were  entirely  empty  ; the  epidermis,  which 
was  raised,  was  thick,  and  of  a brownish-grey  colour.  Others  were  filled  with 
a greyish  liquid,  resembling  the  foetid  ichor  yielded  by  ill-conditioned  ulcers  of 
long  standing.  Others,  in  small  numbers,  presented  themselves  in  the  form  of 
large  blisters  filled  with  a reddish  serum. 

The  gastric  mucous  membrane,  throughout  its  entire  extent,  was  of  a dirty 
greyish-white  colour  ; it  was  not  softened,  but  towards  the  great  cul-de-sac  there 
were  observed  from  five  to  six  brownish  patches  of  a rounded  form,  having,  on 
an  average,  the  diameter  of  a fifteen  sous  piece ; they  were  formed  of  blood 
effused  into  the  submucous  cellular  tissue.  The  mucous  membrane  itself  was 
not  altered. 

The  small  intestine,  generally  white,  presented  from  place  to  place  some  spots 
similar  to  those  of  the  stomach. 

The  caecum  was  red  through  its  entire  extent,  the  rest  of  the  large  intestine 
was  pale. 

Two  ounces  of  reddish  serum  was  found  in  each  of  the  pleurae.  The  right  lung 
presented  on  its  surface  a broad  ecchymosis.  Both  lungs  were  in  every  other 
part  perfectly  healthy. 

The  brain  and  its  membranes  presented  no  appreciable  lesion. 

Certainly,  in  this  case,  none  of  the  alterations  found  in  the  organs  could  account 
for  the  very  serious  phenomena  observed  duringlife,  no  more  than  for  the  patient’s 
death.  We  see  here  nothing  but  an  upsetting  of  all  the  functions,  and  a sudden 
prostration  coinciding  with  the  collapsed  state  of  the  pustules.  Was  the  pus, 
which  filled  them,  having  been  absorbed  all  at  once  and  carried  into  the  circula- 
tion, the  cause  of  the  phenomena  observed  ? This  question  will  perhaps  not  be 
considered  unworthy  of  examination,  if  it  be  recollected  that  animals,  into  whose 
veins  pus  has  been  injected,  present  nearly  the  same  series  of  phenomena,  and 
also  after  death  the  same  description  of  lesion,  as  has  been  ascertained  from  the 
experiments  of  MM.  Magendie,  Gaspard,  Dupuy,  Leuret,  Trousseau,  &c. 

Case  14. — Residence  at  Paris  of  a recent  date;  bad  diet;  distress  — Diarrhoea  at  the  com- 
mencement ; successive  development  of  ataxo-adynamic  symptoms  — Bloodletting  ; blisters ; 
diluent  ptisans  — Ether  and  musk  the  two  last  days  only  — Death  on  the  27th  day  — Gan- 
grene and  ulceration  of  the  follicles  — Stomach  almost  healthy  — Pneumonia  — Blood  as 
it  were  sanious  — Spleen  very  soft. 

A mason,  twenty-one  years  of  age,  of  alymphatico-sanguineous  temperament, 
was  now  residing  in  Paris  for  about  two  months.  Since  his  arrival  he  experienced 
considerable  distress,  and  had  scanty  food.  Towards  the  10th  of  June  he  was 
attacked  with  profuse  diarrhoea,  which  during  the  first  days  did  not  prevent  him 


DISEASES  OF  THE  'ABDOMEN. 


45 


from  eating  his  food' and  attending  to  his  work.  But  the  purgingsoon  increased 
(twenty  stools  in  the  twenty-four  hours)  ; loss  of  appetite  ; debility  constantly 
increasing  ; inability  to  work  ; he  kept  his  bed  for  eight  days  before  entering  the 
hospital ; he  took  no  medicine  ; observed  strict  diet,  and  drank  eau  sucree.  He 
entered  the  hospital  on  the  29th  of  June.  On  the  30th  we  were  struck  with  the 
air  of  stupor  which  he  evinced  ; he  complained  of  intense  frontal  headach.  His 
intellect  was  clear,  his  movements  painful.  The  tongue  covered  with  a whitish 
coat,  was  red  at  the  apex,  and  marked  over  the  remaining  part  with  a number  of 
small  bright  red  points  ; bad  taste  in  the  mouth,  thirst ; loss  of  appetite  ; abdo- 
men free  froqj  pain  and  soft  ; from  fifteen  to  eighteen  watery  stools  with  a yel- 
lowish tint  had  taken  place  since  the  day  before.  Pulse  frequent  and  concentrated, 
skin  hot  and  dry.  A slight  cough  existed.  (Rice  water  with  gum  ; flaxseed 
lavement.) 

In  the  course  of  the  day  it  was  observed  that  the  patient  raved  a little.  In  the 
night  he  disturbed  the  sleep  of  those  near  him  by  his  cries.  On  the  morning  of 
the  1st  of  July  we  found  him  in  nearly  the  same  state  as  on  the  preceding  day. 
The  sputa  appeared  a little  viscid.  (Bleeding  to  two  palettes  ; two  blisters  to 
the  legs.) 

The  blood  taken  from  the  vein  combined  into  a large  coagulum  without  any 
buffy  coat,  remarkably  soft,  and  resembling  currant  jelly.  The  delirium  returned 
during  the  night.  On  the  morning  of  the  2d  his  intellect  was  perfectly  good  ; 
but  he  was  very  much  cast  down,  his  eyes  were  scarcely  open,  tongue  red  and 
its  papillae  prominent,  the  diarrhoea  somewhat  abated,  the  skin  remained  dry, 
the  patient  coughed  more  than  on  the  preceding  days,  and  the  viscidity  of  the 
sputa  continued.  (Rice  water,  flaxseed  lavement.)  The  delirium  returned  during 
the  night. 

On  the  3d  great  despondence  evinced  in  the  countenance,  livid  tint  of  the  face ; 
the  patient  had  considerable  difficulty  in  raising  himself  a little  in  order  to  have 
percussion  and  auscultation  practised.  The  viscidity  of  the  sputa  was  sufficient 
to  make  us  apprehend  the  development  of  pneumonia,  though  the  respiration  did 
not  appear  at  all  embarrassed.  We  heard  a little  crepitus  on  the  posterior  and 
inferior  part  of  the  left  side  of  the  chest.  Five  or  six  livid  spots  of  a rounded 
form  were  scattered  over  the  chest.  The  patient  answered  the  questions  put  to 
him  perfectly  well.  An  hour  after  he  quitted  the  bed  on  a sudden,  and  talked 
very  incoherently.  Two  more  blisters  were  applied  to  the  thighs.  The  re- 
mainder of  the  day  he  raved. 

On  the  4th  the  air  of  stupor  was  carried  to  an  extreme  degree.  The  patient 
appeared  quite  unconscious  of  every  thing  which  passed  around  him.  Still  he 
understood  questions,  and  answered  them  ; but  when  left  to  himself  he  raved 
again.  The  tongue  was  dry,  similar  in  colour  to  that  of  burned  cream  ; the  lips 
and  teeth  were  covered  with  thick  black  crusts;  his  stools  passed  under  him  in 
bed  ; the  heat  of  the  skin  Was  very  acrid  ; the  pulse,  which  was  very  frequent, 
was  easily  compressed ; the  spots  had  disappeared  ; the  patient  did  not  now 
expectorate.  (Barley  water  acidulated  with  muriatic  acid;  fomentations  with 
warm  oxycrat  to  the  abdomen  and  thighs.) 

On  the  5th  the  eyelids  remained  half  depressed  over  the  globe  of  the  eye ; 
when  they  were  raised  the  latter  was  observed  to  be  dull,  and  devoid  of  expres- 
sion ; a sort  of  powder,  of  a dirty  grey  colour,  covered  the  cheeks  ; frequent  sub- 
sultus  tendinum  was  observed  in  the  two  forearms,  and  from  time  to  time  slight 
convulsive  movements  of  the  depressor  muscles  of  the  left  commissure  of  the  lips 
were  noticed.  The  skin  of  the  trunk  and  extremities  retained  its  dryness  and 
acrid  heat ; the  skin  of  the  face,  on  the  contrary,  was  cold  and  covered  with  a 
clammy  sweat.  The  pulse  became  still  weaker.  (The  same  ptisans  and  fomen- 
tations were  continued;  ethereal  mixture  with  twelve  grains  of  musk;  campho- 
rated lavement.)  The  patient  remained  in  nearly  the  same  state  during  the  day. 


4 G 


ANDRAL’S  MEDICAL  CLINIC. 


Sometimes  he  appeared  in  a state  of  profound  coma,  sometimes  he  opened  his 
eyes  and  sighed  very  deeply  ; he  passed  his  stools  several  times  under  him  ; he 
complained  continually  during  the  night. 

At  the  visit  of  the  6th,  his  state  was  nearly  the  same  as  on  the  day  before. 
He  appeared  to  hear  the  questions  addressed  to  him  ; he  put  out  his  tongue  easily 
enough,  but  he  said  not  a word.  The  subsultus  was  now  become  more  frequent. 
The  pulse  was  more  than  120  ; the  tongue  was  dry  as  a bit  of  parchment.  A 
lumbricus  was  passed.  The  inspiration  was  high  and  hurried.  (The  same 
prescription.) 

On  the  7th,  the  patient  was  dying..  We  were  particularly  struck  with  the 
great  frequency  of  the  inspirations.  He  died  some  hours  after  the  visit. 

Post-mortem , eighteen  hours  after  death. 

Cranium. — The  veins  under  the  arachnoid  of  the  convexity  of  the  hemispheres 
were  gorged  with  blood.  The  former  appeared  considerably  injected.  The  cere- 
bral substance  was  dotted  with  a great  quantity  of  small  red  points.  The  ven- 
tricles were  entirely  empty  of  serum  'r  a little  was  found  between  the  cerebellum 
and  its  tentorium. 

Thorax.. — The  lower  lobe  of  the  left  lung  presented  a brownish  colour,  and' 
did  not  crepitate.  It  bore  considerable  resemblance  to  the  tissue  of  certain 
very  soft  spleens.  Everywhere  else  the  lungs  were  perfectly  healthy,  not  en- 
gorged. The  heart  contained  in  its  right  side  some  fibrinous  clots  of  but  little 
consistence,  and  adhering  somewhat  firmly  to  the  carneae  columnae  of  the  auri- 
cular appendix. 

Abdomen. — The  stomach  was  distended  with  gases.  Its  inner  surface  pre- 
sented several  rose-coloured  patches,  in  the  interval  between  which  it  was 
white.  The  mucous  membrane,  examined  in  the  site  of  these  patches  and  be- 
tween them,  had  everywhere  retained  its  natural  thickness  and  consistence; 
this  state  of  the  stomach  might  be  considered  at  most  as  the  first  stage  of  slight 
inflammation. 

The  duodenum,  jejunum,  and  ileum,  contained  a great  quantity  of  yellow  bile. 
These  intestines,  when  opened  through  their  entire  extent,  and  washed,  presented 
their  inner  surface  very  pale  to  within  about  two  feet  and  half  above  the  caecum. 
In  this  latter  part  there  existed  a remarkable  lesion,  which  appeared  to  be  of  the 
same  kind,  and  merely  presented  different  degrees.  Thus  we  observed  in  several 
places  oblong  elevations  of  a brownish  red  colour,  formed  at  the  same  time  both 
by  the  mucous  membrane,  a little  thickened  in  this  part,  and  more  especially  by 
the  subjacent  engorged  laminated  tissue  (1st  stage).  In  other  places  these  same 
elevations  were  surmounted  by  a yellowish  tissue,  intimately  adherent  to  the  sub- 
jacent tissue,  and  altogether  resembling  the  eschars  of  external  parts.  It  appeared 
to  us  beyond  doubt  that  this  tissue  was  nothing  else  than  the  mucous  membrane 
affected  with  gangrene,  whether  alone  or  together  with  the  cellular  tissue  lying 
beneath  it  (2d  stage).  In  other  parts,  the  elevations  no  longer  presented  the 
preceding  yellowish  tissue,  except  in  isolated  points,  and  in  the  intervals  of  this 
tissue  there  was  seen  a tissue  of  a deep  brownish  red  colour.  In  this  latter  case 
the  gangrened  portion  was  already  partly  detached  ; thence  resulted  an  ulcer, 
the  bottom  of  which  was  formed  by  the  laminated  tissue,  thickened  and  inflamed 
(3d  stage).  In  other  places  there  was  observed  only  mere  ulcerations,  without 
any  mixture  of  yellowish  tissue,  with  red  edges  formed  by  the  mucous  mem- 
brane, with  a brownish  bottom  formed  by  the  laminated  tissue  (4th  stage). 

All  these  ulcerations  formed  a considerable  prominence  above  the  mucous 
membrane.  This  was  white,  or  slightly  injected  in  the  intervals. 

The  mucous  membrane  of  the  caecum  and  of  the  commencement  of  the  colon 
presented  considerable  injection.  We  also  observed,  on  all  the  large  intestine, 
several  black  isolated  points,  surrounded  with  a circle  of  a dull  white  colour, 
forming  a slight  prominence  above  the  rest  of  the  mucous  membrane.  (Follicles.) 


DISEASES  OF  THE  ABDOMEN.  47 

The  spleen,  of  a large  size,  was  extremely  soft,  and  contained  a matter  having 
the  colour  of  wine  lees. 

The  other  viscera  were  healthy. 

Examination  of  the  blood. — The  thoracic  descending  aorta  contained  a con- 
siderable quantity  of  blood,  the  appearance  of  which  seemed  very  remarkable. 
It  presented  itself  under  the  form  of  a liquid,  having  the  colour  of  wine  lees,  as 
if  sanious  in  some  parts,  and  holding  suspended  some  small  blackish  globules. 
With  the  exception  of  this  circumstance,  it  presented  a great  resemblance  to 
the  blood  which  escapes^from  an  abscess  opened  before  maturity.  The  rest  of 
the  arterial  system  was  empty.  The  blood  from  the  vena  cava  presented  the 
same  appearance. 

The  circumstances  which  preceded  the  development  of  this  disease  should 
not  be  lost  sight  of : the  patient’s  recent  arrival  in  Paris,  his  distress,  and  bad 
diet.  In  the  midst  of  these  circumstances  a profuse  diarrhoea  came  on  : it 
fatigued  and  exhausted  the  patient,  who  was  placed,  by  causes  which  previously 
acted  on  him,  in  peculiar  conditions  of  innervation  and  hematosis,  and,  from 
the  very  first  day  we  saw  him,  we  were  struck  with  the  air  of  stupor  on  him, 
the  prelude  to  much  more  serious  symptoms.  In  this  state  of  things  venesec- 
tion was  employed,  and  the  appearance  of  the  blood  drawn  from  the  arm  was 
so  unusual,  that  it  already  announced  that  the  function  of  hematosis  was 
changed,  whether  primarily  or  consecutively,  as  well  as  the  function  of  inner- 
vation. This  bleeding  did  not  at  all  arrest  the  progress  of  the  disease;  it  did 
not  even  impede  the  development  of  the  pneumonia  ; and  the  day  after  it  was 
employed  the  general  debility  became  much  greater.  Revulsives  were  no 
longer  efficacious ; and  though  simple  diluent  drinks  were  given,  the  tongue 
became  more  and  more  dry,  in  proportion  as  the  other  symptoms  became  worse. 
The  post-mortem  showed  us  the  same  lesions  as  those  observed  in  the  preced- 
ing cases. 

It  is  always  the  digestive  tube  which  we  find  more  especially  the  seat  of 
lesion,  and  that  lesion  is  always  of  the  same  nature.  On  the  contrary,  we  dis- 
cover nothing  but  considerable  congestion  in  those  nervous  centres  which, 
during  life,  had  presented  such  serious  functional  disturbances,  and  which  the 
disease  principally  seemed  to  reside. 

Let  us  now  direct  our  attention  to  some  particular  circumstances  of  this  dis- 
ease. We  may  first  remark  the  delirium:  it  was  first  intermittent;  then  it 
was  separated  by  lucid  intervals  of  greater  or  less  length ; and,  finally, 
it  became  continued.  Up  to  the  last  day  of  his  life  the  patient,  though  in 
a state  of  delirium,  understood  the  questions  put  to  him  ; and,  even  when  he 
was  no  longer  able  to  speak,  his  actions  showed  that  he  still  comprehended 
them.  Let  us  remark  also  how,  in  a short  space  of  time,  the  manifestation  of 
the  muscular  strength  may  vary  from  some  modification  of  the  nervous  system. 
On  the  3d  of  July,  the  patient,  with  all  his  efforts,  was  unable  to  raise  him- 
self in  the  bed  ; an  hour  after  he  commenced  to  rave;  he  then  sat  up  of  him- 
self, and  walked  several  steps  in  the  room. 

The  skin  remained  constantly  dry.  Two  days  only  before  death  his  face  was 
covered  with  a cold  clammy  sweat.  The  trunk  and  extremities  contrasted  by 
the  burning  heat  with  the  icy  coldness  of  the  cheeks.  This  unequal  distribu- 
tion of  heat  disappeared  the  next  day. 

In  this  case,  as  in  several  of  the  preceding,  the  state  of  the  tongue  did  notin- 
dicate  the  state  of  the  stomach.  The  lesion  which  the  latter  presented  con- 
sisted merely  in  a very  slight  injection,  similar  to  that  found  on  most  dead 
bodies,  and  yet  the  tongue  was  to  the  end  remarkably  dry  ; the  lips  and  teeth 
presented  thick  dark  crusts.  These  phenomena  appeared  also  at  a period  when 
the  patient  had  as  yet  taken  but  simple  diluent  drinks. 

No  abdominal  pain  ; no  tympanitis  announced  the  serious  alteration  of  the 
intestine. 


48 


ANDliAL’S  MEDICAL  CLINIC. 


The  diarrhoea  which  came  on  from  the  commencement  of  the  disease,  and 
which  then  progressively  diminished,  was  thus  caused,  at  first,  by  an  acute 
inflammation  of  the  follicles  of  the  large  intestine,  an  inflammation  which  no 
longer  existed  at  the  time  of  death,  but  the  former  existence  of  which  seemed 
to  be  proved  by  the  unusual  development  of  the  caecum  and  colon.  It  has  often 
occurred  to  us  to  find  nothing  else  but  these  follicles  thus  developed  in  cases  of 
diarrhoea  of  a more  or  less  ancient  standing. 

The  alteration  of  the  lung  had  no  doubt  its  share  in  the  production  of  the 
different  nervous  symptoms  : viscid  sputa,  not,  however,  streaked  with  blood, 
were  the  only  symptom  which  caused  us  at  first  to  suspect  the  existence  of  a 
pneumonia.  The  respiration  was  impeded  only  towards  the  termination ; 
then  the  dyspnoea  became  such  as  to  engage  our  attention  very  much ; but 
we  should  not  forget  that  very  often,  towards  the  close  of  typhoid  fevers,  the 
breathing  may  be  considerably  accelerated,  and  the  lungs  still  remain  healthy. 
We  have  seen  the  kind  of  alteration  which  the  lung  presented  ; it  was  remark- 
able for  its  extreme  friability,  and  for  the  great  quantity  of  liquid  with  which 
it  was  engorged.  The  air  no  longer  penetrated  the  diseased  part,  and  yet  there 
was  neither  red  nor  grey  hepatisation.  It  was  a peculiar  alteration,  which  it 
is  not  uncommon  to  meet  in  cases  of  dothinenterite,  with  dark  incrustations  of 
the  mouth,  petechise,  pultaceous  softening  of  the  spleen,  &c. 

What  shall  we  say  of  these  spots,  larger  than  ordinary  petechiae,  with  which 
the  chest  was  covered  on  the  5 th  of  July?  They  lasted  but  twenty-four  hours, 
and  did  not  coincide  with  any  appreciable  change  in  the  other  phenomena  of 
the  disease.  These  spots,  designated  by  authors  under  the  name  of  vibices , are, 
says  Huxham,  a certain  sign  of  the  presence  of  malignity.  They  are  often  ac- 
companied with  profuse  hemorrhages,  and,  according  to  the  system  of  the  old 
humourists,  they  were  connected  with  a morbid  state  of  the  blood. 

In  the  case  now  before  us  there  was,  in  fact,  a very  appreciable  alteration  of 
the  blood.  It  was  evident  in  the  blood  drawn  during  life  ; it  was  still  more  so 
in  the  dead  body.  Now,  is  it  in  this  blood,  thus  altered,  that  we  must  seek 
for  the  outset  and  cause  of  the  different  functional  or  organic  disturbances  pre- 
sented by  the  patient?  Let  us  first  remark,  that,  in  most  of  the  individuals  who 
form  the  subject  of  the  preceding  cases,  we  observed  almost  the  same  disorders, 
whether  during  life  or  after  death,  and  that,  in  several  of  them,  the  blood  did 
not  seem  to  us  to  deviate  from  its  normal  state.  One  might  just  as  well  main- 
tain that  the  alteration  of  the  blood  was  here  consecutive  ; that  it  was,  for  in- 
stance, the  result  of  the  absorption  of  the  gangrenous  parts  of  the  intestine,  but 
that  would  be  mere  hypothesis  ; and,  besides,  it  would  not  account  for  the 
alteration  presented  by  the  blood  drawn  from  the  vein  at  a period  when  it 
could  not  yet  be  admitted  that  the  absorption  of  which  we  have  just  spoken 
was  the  cause  of  it.  However,  whatever  may  have  been  the  part  which  the 
alteration  of  the  blood  performed  here,  this  alteration  was  at  all  events  real,  and 
must  have  exercised  some  influence  on  the  symptoms,  progress,  and  termina- 
tion of  the  disease ; for  it  can  scarcely  be  conceived  that  the  different  tissues 
could  be  nourished  and  excited  by  blood  thus  altered,  without  themselves  ex- 
periencing some  disturbance. 


Case  15.  — Recent  arrival  in  Paris  — At  the  commencement  quotidian  remittent  fever,  with 
evident  signs  of  gastro-intestinal  irritation  — subsequently  adynamic  symptoms,  preceded 
by  profuse  epistaxis — Bleeding,  blisters ; diluent  drinks — Death  on  the  twentieth  day  — 
Follicles  of  the  ileum,  crecum,  and  colon,  tumefied  and  ulcerated  — Purulent  infiltration  of 
the  lower  lobe  of  the  left  lung  — Gangrene  of  the  upper  lobe  of  the  same  lung. 

A water-carrier,  twenty-five  years  of  age,  who  had  come  to  Paris  from  Savoy 
within  the  last  three  months,  of  a sanguineous  temperament  and  strong  make, 
was  seized,  on  the  evening  of  the  17th  of  January,  with  shiverings,  which  con- 


DISEASES  OF  THE  ABDOMEN. 


49 


tinued  during  the  night ; on  the  day  after  a feeling  of  general  illness,  appetite 
diminished;  returns  of  the  shivering  at  night;  frequent  alvine  evacuations, 
attended  with  colicky  pains ; he  was  not  submitted  to  any  treatment  up  to  the 
24th  ; he  then  entered  the  hospital. 

On  the  25th  (ninth  day)  countenance  flushed,  eyes  very  bright,  thirst,  loss  of 
appetite  ; tongue  red  at  the  edges  and  apex,  covered  with  a yellowish  coat  at  the 
centre  ; bitter  taste  in  the  mouth  ; abdomen  free  from  pain,  and  a little  swollen  ; 
from  seven  to  eight  stools  in  the  twenty-four  hours  ; slight  cough  ; pulse  full  and 
frequent,  skin  hotand  dry.  (Venesection  to  four  palettes  ; barley-ptisan  sweetened ; 
diet.) 

On  the  26th  the  blood  presented  a large  clot,  covered  with  a dense  and  thick 
huffy  coat;  fourteen  stools  ; same  state  in  other  respects.  (Venesection  to  two 
palettes.) 

On  the  evening  of  the  26th  a very  violent  exacerbation  of  the  fever.  (Third 
venesection  to  the  extent  of  one  palette,  after  which  the  patient  fainted.) 

On  the  27th  slight  epistaxis  ; in  the  evening  violent  fever.  (Bleeding  to  two 
palettes.)  The  blood  presented  a small  clot,  covered  with  a thin,  soft,  buffy  coat. 

On  the  28th  epistaxis  ; face  still  flushed,  eyes  very  bright,  but  still  a sinking  of 
the  features  ; answers  questions  very  slowly  ; same  state  of  the  tongue  ; burning 
thirst;  abdomen  a little  tympanitic;  from  thirteen  to  fourteen  stools,  with  colic  ; 
pulse  frequent,  skin  moist.  (Emollient  ptisans.) 

On  the  29th  profuse  epistaxis  ; great  sinking;  continual  complaints  ; cough 
without  expectoration  ; breathing  a little  hurried  ; slight  dulness  and  crepitous 
rale  posteriorly  on  the  left,  over  nearly  the  entire  extent  of  the  lower  lobe. 
(Twenty-four  leeches  to  the  left  side  of  the  chest ; two  blisters  to  the  legs.) 

30th  and  31st,  epistaxis,  prostration  ; face  pale  ; same  state  of  the  breathing  ; 
same  result  from  percussion  and  auscultation;  expectoration  catarrhal ; diarrhoea 
also  profuse.  (Blister  to  the  chest.) 

The  1st  February,  intellects  disturbed  ; epistaxis. 

2d,  profuse  epistaxis  since  three  in  the  morning;  extreme  debility  ; counte- 
nance pale  and  despondent ; tongue  white  and  moist ; breathing  freer  ; continuance 
of  the  cough,  meteorism  and  diarrhoea  ; pulse  very  frequent  and  weak.  (Nasal 
cavities  plugged  ; rice  water  with  gum.) 

On  the  3d,  great  uneasiness  during  the  night ; eyes  flushed  ; talkative  ; con- 
stant moving  of  the  lower  jaw  ; pulse  weak,  and  very  frequent;  tongue  moist  and 
white.  (Sinapisms.) 

On  the  4th,  tongue  white,  but  dry,  with  some  black  patches  ; teeth  black  ; pulse 
100,  and  very  weak. 

On  the  5th,  extreme  prostration  ; continual  groaning  ; intellects  perfect;  invo- 
luntary discharge  of  fasces  ; breathing  high  and  loud  ; the  bladder,  which  is  dis- 
tended, ascends  to  the  umbilicus  ; overflowing  of  the  urine ; pulse  very  weak,  1 40. 
(Decoction  of  polygala  with  gum  ; blister  to  the  sternum  ; sinapisms  to  the  thighs.) 

He  died  at  eleven  o’clock  in  the  morning. 

Post-mortem.  Brain  healthy. 

Thorax.  — Close  adhesion  of  the  pleurae  costalis  and  pulmonalis  of  the  left 
side  ; lower  lobe  of  the  left  lung  dense,  brownish,  and,  on  making  an  incision 
into  it,  a mixture  of  blood  and  pus  escaped.  In  the  centre  of  the  upper  lobe, 
which  was  healthy,  we  found  a cavity  capable  of  containing  a large  egg.  Its 
surface  was  areolated,  brownish,  and  contained  a sort  of  pap  of  a greenish-grey 
colour,  and  a gangrenous  fetid  odour. 

Abdomen.  — Gastric  mucous  membrane  very  white  through  its  entire  extent, 
being  also  of  its  ordinary  thickness  and  consistence;  remarkable  paleness  of  the 
mucous  membrane  of  the  small  intestine  in  its  upper  four-fifths.  In  the  lower 
fifth  there  were  found  numerous  elevations,  the  diameter  of  which  varied  from 
three  to  six  lines.  They  were  of  a pale  rose  colour.  Some  were  ulcerated  in 
5 


50 


ANDRAL’S  MEDICAL  CLINIC. 


the  centre  ; over  the  extent  of  some  fingers’  breadth  above  the  valve  we  found 
several  ulcerations,  being  about  the  diameter  of  a forty  sous  piece.  The  mucous 
membrane  forming  their  edges  was  red  and  puffy. 

The  internal  surface  of  the  caecum  and  colon  was  studded  with  elevations 
similar  to  those  of  the  small  intestine,  but  more  confluent,  and  ulcerated  for  the 
most  part  at  their  centre.  The  mucous  membrane  was  red  to  its  entire  extent, 
whilst  it  was  white  in  the  small  intestine. 

The  lymphatic  ganglions,  corresponding  to  the  portions  of  the  diseased  intes- 
tine were  swollen,  and  their  tissue  red. 

The  bladder,  distended  by  urine,  extended  as  far  as  the  umbilicus.  Its  inter- 
nal membrane  was  slightly  injected. 

Let  us  try  to  point  out  the  most  striking  phenomena  of  this  disease.  It  attacked 
a man  of  a'vigorous  constitution,  who  had  recently  come  to  Paris.  It  commenced 
with  shivering,  which  returned  every  evening  for  three  consecutive  days  ; purg- 
ing set  in  on  the  third  day ; the  patient  remained  at  rest,  without  taking  any 
medicine,  up  to  the  ninth  day.  Then  the  tongue  became  red,  the  purging  con- 
siderable, the  abdomen  free  from  pain,  pulse  feverish  ; the  strength  was  still  re- 
tained. On  the  three  following  days,  25th,  26th,  and  27th  January,  three  bleed- 
ings were  employed;  the  blood  was  buffed  in  all  ; still  no  amendment,  27th, 
28th,  and  29th,  epistaxis  each  day  ; countenance  begins  to  be  expressive  of  de- 
jection ; on  the  29th  symptoms  of  pneumonia;  leeehes  to  the  chest,  blisters  to 
the  legs.  From  the  30th  January  to  5th  February,  epistaxis  so  profuse  as  to 
render  plugging  necessary  ; from  this  moment  the  prostration  of  strength  went 
on  increasing  ; there  was  dryness , and  at  the  same  time  paleness,  of  the  tongue  ; 
purging  still  continued;  meteorism,  delirium  at  intervals;  dyspnoea,  paralysis 
of  the  bladder,  debility  and  extreme  frequency  of  the  pulse  : death. 

To  explain  these  different  symptoms  we  discover  nothing  in  the  nervous  cen- 
tres ; but  we  find  in  the  intestine  the  ordinary  disease  of  the  follicles  at  the  dou- 
ble period  of  exantheme  and  ulceration.  The  stomach  was  free  from  all  lesion, 
though  the  tongue  had  been  dry  and  black.  Farther,  we  find  two  different  alter- 
ations in  the  left  lung  ; inferiorly  a pneumonia,  which  terminated  by  suppuration  ; 
superiorly  a cavity,  which,  existing  in  the  middle  of  the  pulmonary  parenchyma, 
presented  all  the  characters  of  gangrene  of  the  lung,  such  as  they  are  described 
by  Laennec,  when  a cavity  results  from  softening,  and  from  the  putrid  abscess  of 
the  portion  of  the  lung  which  had  become  gangrened.  This  cavity  also  did  not 
communicate  with  any  bronchus,  so  that  the  sputa  did  not  present  any  peculiar 
character.  But  what  became  of  the  gangrenous  matter?  Had  it  been  taken  up 
by  absorption,  and  carried  into  the  torrent  of  the  circulation  ? At  what  period 
did  this  gangrene  form  ? What  relation  between  it  and  the  other  symptoms? 
Knowing  the  impossibility  of  solving  these  queries  with  anything  like  accuracy, 
we  shall  merely  remark  here,  that  real  gangrene  of  the  lung  is  but  very  rarely 
seen  in  the  diseases  called  typhoid  fevers;  and  consequently,  that  whatever  is 
found  written  in  ancient  authors  on  the  frequency  of  gangrene  of  the  lungs  in  such 
cases  cannot  be  justified  by  observation. 

In  this  case,  moreover,  as  in  all  those  which  have  been  previously  cited,  the 
pneumonia  would  have  been  overlooked,  if  the  chest  had  not  been  percussed 
and  auscultated.  We  cannot,  therefore,  impress  it  too  strongly  on  physicians 
to  practise  percussion  and  auscultation  as  often  as  possible  in  the  case  of  patients 
attacked  with  typhoid  fever.  In  the  majority  of  cases  it  is  only  by  having  re- 
course to  this  double  method  of  investigation  that  they  will  be  apprised  of  the 
existence  of  those  intercurrent  pneumonias,  so  insidious  in  their  invasion,  so 
obscure  in  their  progress  and  in  their  symptoms,  and  so  destructive  in  their 
results. 

It  appears  to  us  remarkable,  that  it  was  after  bleeding  employed  for  three  suc- 
cessive days,  which  was  unable  to  arrest  the  disease,  that  those  profuse  attacks  of 


DISEASES  OF  THE  ABDOMEN. 


51 


epistaxis  came  on,  the  appearance  of  which  preceded  .that  of  the  adynamic  symp- 
toms. We  dwell  so  much  the  more  readily  on  this  succession  of  phenomena, 
as  it  is  not  the  only  time  we  have  observed  it.  In  the  winter  of  1829,  in  par- 
ticular, we  saw  in  five  medical  students,  labouring  under  slight  continued  fever, 
large  bleedings,  employed  in  rapid  succession,  followed  by  repeated  attacks  of 
epistaxis,  which  were  themselves,  as  it>were,  the  prelude  to  a most  serious 
ataxic  or  adynamic  state.  In  two  of  them,  a little  time  after  these  attacks  of 
epistaxis  came  on,  we  saw  several  of  the  leech-bites  ulcerate.  Each  ulceration 
was  rounded,  and  seemed  to  have  been  made,  as  it  were,  by  a shoemaker’s  nip- 
ping tool.  These  two  individuals  died.  We  think,  that  the  more  blood  we 
should  have  taken  from  these  patients,  the  more  we  should  have  increased  the 
tendency  of  all  the  irritated  parts  to  ulceration. 

Case  16.  — Residence  for  some  years  in  Paris  — Previous  watching  and  fatigue  — At  first 
mere  lassitude,  then  slight  continued  fever,  becoming  more  severe  according  as  the  symptoms 
of  pulmonary  and  gastro-intestinal  irritation  became  well  marked  — Sudden  return  of  pros- 
tration, and  death  on  the  thirty -first  day  in  the  midst  of  an  apparent  state  of  half-convales- 
cence— Ulcerations  in  the  place  normally  occupied  by  the  follicles  of  the  ileum  — Black 
colour  and  softening  in  the  patches  of  the  intestinal  mucous  membrane  — Pneumonia. 

A gilder,  seventeen  years  of  age,  of  a delicate  constitution  and  lymphatic  tem- 
perament, who  had  been  residing  in  Paris  for  some  years,  devoted  himself,  for 
several  consecutive  days,  to  excessive  labour,  which  was  prolonged  for  a consi- 
derable part  of  the  night.  On  the  26th  of  December  he  had  some  shivering  fits 
in  the  evening  ; his  sleep  was  uneasy  and  disturbed.  On  the  day  after,  and  the 
three  following  days,  he  employed  himself  at  his  ordinary  work  ; but,  from  time 
to  time,  unusual  fatjgue  obliged  him  to  rest.  He  was  then  seized  with  a shiver- 
ing, followed  by  heat.  On  the  3d  of  January  he  kept  his  bed.  At  this  period 
there  existed  an  annoying  feeling  of  heat,  thirst,  complete  loss  of  appetite,  feeling 
of  debility,  shivering  in  the  evening,  want  of  sleep,  constipation.  This  state 
continued  for  six  days.  Finding  himself  worse  on  the  10th  of  January,  he  had 
a physician  brought  to  him,  who  prescribed  twenty  leeches  to  the  anus,  and  an 
emollient  lavement.  These  means  relieved  him  a little.  On  the  12th  he  entered 
the  hospital. 

State  on  the  13th  ; feeling  of  weakness,  noheadach,  face  pale  ; tongue  moist, 
white  in  the  centre,  red  at  the  edges  and  apex  ; thirst,  anorexia,  abdomen  soft 
and  free  from  pain,  constipation  ; pulse  of  moderate  frequency  ; skin  hot  and  dry. 
In  such  a state  of  things,  no  precise  indication  presented  itself.  (Barley  ptisan, 
lavement  of  marshmallow.) 

On  the  14th  and  15th  the  patient  found  himself  better.  He  was  less  dejected, 
the  skin  was  becoming  moist,  pulse  was  soft ; one  alvine  evacuation  had  taken 
place  in  twenty  four  hours.  (The  same  prescription.) 

On  the  16th  the  face  was  flushed  ; fever  more  intense.  The  patient  coughed 
without  expectorating  ; his  breathing  was  a little  hurried.  The  chest,  when  per- 
cussed, yielded  a somewhat  dull  sound  on  the  inferior  and  posterior  part  of  the 
left  side  ; there  also  the  crepitous  rale  was  heard.  These  evident  symptoms  of 
pneumonia  were  combated  by  the  application  of  fifteen  leeches  to  the  left  side. 
(Demulcent  drinks.) 

On  the  17th,  the  sound  was  duller  on  the  left ; the  crepitious  rale  was  less 
marked,  and  without  any  mixture  of  the  natural  respiratory  murmur.  The  sputa 
were  transparent,  viscid,  a little  rusty-coloured  ; the  inspirations  were  short  and 
frequent.  The  pneumonia  appeared  to  progress  towards  hepatisation.  On  the 
other  hand,  the  state  of  dejection  was  increased,  the  countenance  was  pale,  and 
expressive  of  great  prostration  ; the  pulse  was  more  frequent  and  weaker;  skin 
dry,  and  free  from  heat ; the  abdomen  tympanitic,  always  free  from  pain  ; tongue 
continued  moist ; one  alvine  evacuation  only  took  place  after  the  administration 


52 


ANDRAL’S  MEDICAL  CLINIC. 


of  an  emollientlavement.  s This  general  debility,  this  absence  of  reaction,  seemed 
to  contraindicate  the  employment  of  bloodletting.  A large  blister  was  applied 
over  the  left  side  of  the  chest.  The  action  of  the  skin  was  solicited  by  ten  grains 
of  Dover’s  powder.  (Camomile  lavement.) 

On  the  18th,  worse  in  every  respect.  The  total  absence  of  respiration  on 
the  left  side,  and  at  the  same  time  the  disappearance  of  the  crepitous  rale 
announced  hepatisation  of  the  lower  lobe  of  the  lung  ; the  expectoration  was 
suppressed  ; the  difficulty  of  breathing  had  increased;  a moderate  purging  had 
succeeded  the  constipation  of  the  preceding  days  (five  serous  stools).  The  leaden 
tint  of  the  face  announced  the  progress  of  the  prostration.  (Sinapisms  to  the 
feet.) 

Nothing  new  on  the  19th  ; application  of  a blister  to  one  thigh. 

On  the  20th,  the  breathing  was  more  free,  the  expectoration  was  re-established ; 
but  the  tongue  was  found  dry  for  the  first  time ; there  was  considerable  meteorism  ; 
the  diarrhoea  continued.  Thus  the  improvement  which  occurred,  with  respect  to 
the  chest,  appeared  to  be  at  the  expense  of  the  abdominal  viscera. 

On  the  21st  and  22d,  delirium  from  time  to  time  ; same  state  in  other  respects. 
(Emollient  ptisans.) 

On  the  23d,  there  was  a perceptible  amendment;  nothing  seemed  to  indicate 
it  on  the  preceding  day  ; no  critical  phenomenon  accounted  for  it ; the  skin  in 
particular  retained  its  dryness.  Intellect  clear;  tongue  moist;  meteorism 
diminished,  as  also  the  purging.  On  the  part  of  the  chest  the  improvement  was 
not  less  marked  ; the  breathing  was  free,  cough  infrequent,  expectoration 
catarrhal.  Still  the  dull  sound  and  the  absence  of  the  respiration  continued. 
Thus  the  pneumonia  was  far  from  being  resolved  : but  it  passed  into  the  chronic 
state.  The  pulse  remained  frequent  and  weak.  To  support  the  strength  without 
producing  irritation  of  any  organ,  such  appeared  to  be  the  indication  to  fulfil. 
Aromatic  frictions  were  made  on  the  extremities  several  times  in  the  day.  The 
blister  to  the  thigh  was  dry  ; that  of  the  chest  was  still  kept  up.  Internally 
barley-ptisan  with  gum,  rice-water,  &c.,  were  given.  From  the  24th  to  the 
28th,  the  state  of  the  patient  became  more  and  more  improved.  On  the  27th 
there  was  no  longer  any  symptom  with  respect  to  the  digestive  passages,  ex- 
cept a very  slight  diarrhoea.  (Two  liquid  stools  in  twenty-four  hours.)  The 
strength  was  increased  : the  countenance  assumed  an  excellent  appearance  : the 
dulness  of  sound  and  absence  of  respiration  were  the  only  signs,  which  indi- 
cated that  the  pneumonia  was  not  resolved  ; on  it  alone  seemed  to  depend  the 
continuance  of  a slight  frequency  of  the  pulse,  without  heat  of  skin  ; but  every 
thing  seemed  to  promise  that  time  aided  by  proper  care  would  gradually  effect 
the  resolution  of  this  latent  inflammation. 

What  was  our  astonishment  when,  on  the  morning  of  the  28th,  we  found  the 
patient  in  a worse  state  than  he  had  ever  been.  Face  cadaverous  ; continual 
groaning  ; half-coma  ; no  answers  to  questions  ; pulse  very  frequent  and  thready. 
Numerous  alvine  evacuations  had  taken  place  during  the  night.  We  were 
unable  to  attribute  this  relapse  to  any  cause,  which  was  as  sudden  and  as  un- 
expected as  the  improvement  of  the  23d  had  been. 

The  patient  died  a few  hours  after  the  visit,  on  the  31st  day  from  the  com- 
mencement of  the  continued  fever,  and  on  the  12th  day  of  the  pneumonia. 

Post-mortem , thirty-two  hours  after  death.  Total  absence  of  fat  under  the 
skin  and  around  the  organs  where  it  is  ordinarily  accumulated. 

Cranium. — Brain  perceptibly  more  consistent  than  usual ; ventricles  contain- 
ing about  a large  spoonful  of  limpid  serum. 

Thorax. — The  lower  lobe  of  the  left  lung,  to  about  three-fourths  of  its  extent, 
the  base  of  the  right  lung  to  about  three  fingers’  breadth  in  depth,  presented,  on 
being  cut  into,  a uniform  red  tissue,  whence  a sanious  liquid  flowed.  This 
tissue,  which  was  easily  torn,  did  not  crepitate,  nor  did  it  float  on  water.  The 
lungs,  for  the  remainder  of  their  extent,  were  very  healthy. 


DISEASES  OF  THE  ABDOMEN. 


53 


•Abdomen.  — The  stomach  was  distended  with  gases.  Its  inner  surface  was 
white,  except  in  some  isolated  points  where  there  existed  some  redness  in  the 
form  of  lines  or  small  patches.  These  different  parts,  when  put  together,  equalled 
about  the  diameter  of  a forty  sous  piece.  Their  colour  resided  in  the  mucous 
membrane,  which  there  was  a little  softened. 

The  upper  three-fourths  of  the  small  intestine,  filled  with  a yellow  and  viscid 
liquid,  were  remarkably  white.  At  the  commencement  of  the  lower  fourth, 
we  observed  some  black  patches  seated  in  the  mucous  membrane,  which  was 
thickened  and  softened.  In  the  centre  of  some  we  perceived  a slight  solution  of 
continuity  of  the  mucous  membrane.  In  others,  this  solution  of  continuity 
was  more  deep-seated,  and  more  extensive;  its  bottom  was  formed  of  laminated 
tissue,  which  had  retained  its  whiteness.  According  as  we  approached  the 
termination  of  this  small  intestine,  these  patches  and  these  ulcerations  became 
more  confluent.  Immediately  above  the  ileo-caecal  valve,  and  in  the  caecum, 
there  was  observed  another  kind  of  ulcerations  ; their  edges  were  red  and  puffed  ; 
the  muscular  tunic  constituted  their  bottom.  In  the  interval  between  these 
different  lesions  the  mucous  membrane  was  white.  The  three  portions  of  the 
colon,  whose  inner  surface  was  white,  were  distended  with  gases.  The  sig- 
moid flexure  was  contracted.  The  mucous  membrane  presented  red  folds. 
The  mesenteric  ganglions,  which  corresponded  to  the  lower  third  of  the  small 
intestine,  were  red  and  swollen. 

The  subject  of  this  case  differs  from  several  of  the  preceding  in  this,  that  he 
was  for  a long  time  residing  in  Paris,  when  his  health  began  to  fail.  The  com- 
mencement of  the  disease  is  worthy  of  remark;  when  we  reflect  on  the  nature 
of  the  symptoms  which  this  individual  experienced  at  first,  does  it  not  seem 
that  we  should  refer  them  principally  to  an  exhaustion  of  the  innervation,  pro- 
duced by  watching,  and  by  the  painful  employments  in  which  he  was  engaged  1 
These  are  the  very  symptoms  which  we  perceive  supervene  in  other  indivi- 
duals, whether  after  strong  mental  emotions,  or  after  great  intellectual  fatigue, 
or  after  venereal  excesses,  etc.  Shall  we  then  say,  that,  in  these  cases,  there 
is  at  first  this  general  affection?  What  can  be  less  appropriate  under  the  pre- 
sent circumstances  than  such  an  expression,  and  what  affection  is  better  local- 
ised than  that  which  consists  in  a primary  derangement  of  the  nervous  centres  ? 

However,  in  our  patient,  as  in  most  of  those  who,  by  some  one  of  the  causes 
just  now  stated,  exhaust  their  store  of  innervation  very  excessively,  a pe- 
riod soon  arrived,  when  several  organs  became  the  seat  of  irritation  ; in  this 
case  it  was  principally  the  respiratory  and  digestive  apparatuses.  A congestion 
in  these  organs  being  once  produced,  it  must  be  foreseen  that  it  would  not  be 
readily  resolved,  and  that  there  would  be  a tendency  to  other  terminations  ; it 
must  also  be  apprehended  that  it  would  produce  nervous  symptoms  more  or 
less  serious;  as  is  commonly  observed  in  an  individual  placed  under  circum- 
stances similar  to  those  to  which  our  patient  had  been  subjected. 

No  alarming  symptom  at  first  accompanied  the  double  congestion,  of 
which  the  pulmonary  and  gastro-intestinal  mucous  membranes  were  almost 
simultaneously  the  seat;  however,  the  irritation  of  the  pulmonary  mucous 
membrane  extended  to  the  last  bronchial  ramifications,  reached  the  pulmo- 
nary vesicles,  and  scarcely  had  auscultation  detected  a pneumonia,  when  the 
patient  was  observed  to  fall  into  still  greater  prostration.  There  is  no  doubt 
but  this  pneumonia  contributed  very  much  to  produce  the  adynamic  state  ; this 
is  what  happens  in  many  old  persons  who  are  observed  to  become  adynamic 
very  rapidly,  when  attacked  with  pneumonia.  However,  the  digestive  passages 
had  also  their  share  in  the  production  of  this  adynamic  state,  as  was  proved  by 
the  meteorism  and  diarrhoea  which  set  in. 

Thus  there  are  three  stages  in  this  disease  : in  the  first,  the  derangement  of 
the  health  results  from  prolonged  fatigue  of  innervation,  every  thing  observed 
5* 


54 


ANDRAL’S  MEDICAL  CLINIC. 


may  be  explained  by  this  fatigue,  and  nothing  proves  that  there  was  any  thing 
else  in  question. 

In  the  second  stage,  the  respiratory  and  digestive  passages  become  affected  ; 
but  the  disease  did  not  as  yet  present  any  thing  formidable. 

In  the  third  stage,  the  twofold  affection  of  the  pulmonary  and  gastrointes- 
tinal mucous  membrane  became  more  serious,  and  tiiis  increase  of  severity  was 
announced  by  an  adynamic  state. 

This  third  stage  was  soon  succeeded  by  another,  in  which  the  disease  again 
changed  its  aspect.  Of  the  local  signs  of  the  intestinal  affection  there  now  re- 
mained not  one,  except  a very  slight  diarrhoea  ; of  the  signs  of  the  pneumonia 
there  remained  none  but  those  afforded  by  auscultation  and  percussion  : lastly, 
of  the  general  symptoms  there  remained  merely  a very  slight  febrile  disturbance  ; 
but  the  strength  returned  and  all  the  phenomena  of  adynamia  disappeared. 

This  fourth  stage  seemed  such  as  should  bring  the  patient  to  a perfect  con- 
valescence ; one  might  hope  for  the  complete,  though  slow,  resolution  of  the 
pulmonary  and  intestinal  inflammation,  when  all  at  once  the  scene  changes : 
without  any  known  cause  the  diarrhoea  suddenly  returns  very  profusely  ; at 
the  same  time  the  prostration  of  strength  all  at  once  becomes  extreme,  and  the 
patient  dies,  presenting  a group  of  symptoms  very  much  resembling  those  of 
cholera. 

The  post-mortem  examination  showed  in  the  intestine  lesions  which  certainly 
existed  there  before  the  appearance  of  the  latter  symptoms.  These  lesions 
were  still  very  intense  ; they  were  much  more  considerable  than  those  pre- 
sented by  other  individuals  who  had  died  with  ataxic  or  adynamic  symptoms. 
These  symptoms  had  also  existed  in  our  patient ; but  they  had  disappeared, 
though  the  intestinal  lesion  was  still  very  intense,  as  the  dyspnoea  had  disap- 
peared in  him,  though  at  the  time  of  death  a considerable  portion  of  the  pul- 
monary parenchyma  was  still  hepatised.  We  may  remark  the  state  of  the 
ulcerations  of  the  caecum,  the  edges  of  which  were  still  very  red,  and  which 
were  so  deep-seated  that  their  bottom  was  formed  by  the  muscular  tunic 
divested  of  the  cellular  layer  which  ordinarily  covers  it. 

With  respect  to  the  symptoms  of  the  fifth  stage,  how  are  we  to  account  for 
them  ? Did  they  result  from  a return  of  the  inflammation  of  the  ulcerations  of 
the  caecum,  or  from  a return  of  a profuse  diarrhoea,  breaking  up  of  the  strength, 
and  death  ? 

Be  that  as  it  may,  on  seeing  this  individual  recover  his  strength  and  progress 
towards  convalescence,  who  could  have  supposed  that  there  were  still  such 
serious  lesions  in  the  intestine  ? Who  could  have  supposed  that  he  could  still 
respire  only  by  means  of  a part  of  his  lung  ? From  the  aggregate  of  the  symp- 
toms, whether  local  or  general,  who  would  not  have  formed  a favourable  pro- 
gnosis with  respect  to  the  termination  of  the  disease  up  to  the  morning  of  the 
28th  of  December  ? 

This  patient  was  not  bled.  All  the  treatment  was  confined  to  blisters  ap- 
plied to  the  extremities  and  chest,  to  sinapisms,  to  simple  emollient  drinks,  to 
which  were  added,  on  one  occasion,  ten  grains  of  Dover’s  powder,  which  pro- 
duced no  perspiration.  Tt  was  on  the  day  in  which  this  powder  was  admin- 
istered that  the  diarrhoea  appeared  for  the  first  time. 

Case  17. — Recent  arrival  at  Paris — Great  fatigue  and  watching. — At  the  time  of  entering  the 
hospital  symptoms  of  pneumonia  without  expectoration  ; at  a later  period  ataxo-adynamic 
symptoms — Blood  very  serous — Antiphlogistic  treatment  at  first,  then  tonic — Death  on  the 
34th  day — Intestinal  follicles  tumefied  and  ulcerated;  eschars  at  the  bottom  of  some  ulcera- 
tions— Remarkable  paleness  of  the  ulcerations  and  elevations ; no  redness  of  the  remainder 
of  the  intestines — Pneumonia — Spleen  large  and  soft, 

A woman,  twenty-three  years  of  age,  who  had  arrived  at  Paris  within  the  last 
eight  months,  and  lived  as  a servant,  was  seized  without  any  known  cause,  towards 
the  15th  of  February,  with  illness  and  lassitude  ; her  appetite  was  diminished  ; 


DISEASES  OF  THE  ABDOMEN. 


55 


her  menses  were  suppressed  ; however,  she  continued  to  work  up  to  the  2d  of 
March.  At  this  time  some  cough  and  a pain  in  the  right  side  appeared.  She 
was  bled  in  the  arm,  and  the  day  after  the  bleedingsixteen  leeches  were  applied 
to  the  side  affected.  The  state  of  the  patient  was  not  improved.  She  entered 
the  Charite  on  the  9th  of  March,  and  the  next  day  presented  the  following 
state  : — 

Lies  on  her  back  ; countenance  pale,  with  some  appearance  of  dejection ; 
tongue  white  ; anorexia  ; abdomen  slightly  tumefied,  soft,  painful  on  pressure  in 
the  right  flank  ; two  or  three  stools  ; cough  without  expectoration  ; wandering 
pains  in  the  chest;  on  percussing  we  discovered  a dull  sound  laterally,  on  the 
right  and  left  below  the  mamma  ; respiration  not  heard  on  the  right ; some  rale 
on  the  left  side  ; pulse  frequent  and  hard  ; skin  hot  and  dry.  (She  was  bled  to 
the  amount  of  three  palettes;  two  blisters  to  the  legs  in  the  afternoon;  mucila- 
ginous drinks.) 

The  colour  of  the  blood  less  deep  than  usual ; it  gave  to  the  linen  cloth  a 
very  clear  red  tint,  as  if  the  colouring  matter  were  diluted  with  a considerable 
quantity  of  water.  Being  almost  entirely  constituted  of  serum,  it  presented  but 
a very  thin  coagulum,  about  the  size  of  a five  franc  piece,  and  without  a buffy 
coat. 

On  the  11th,  delirium  during  the  night;  pulse  weaker;  respiration  not  fre- 
quent ; the  other  symptoms  underwent  no  change.  It  appeared  to  us  that  the  dull 
sound  detected  on  the  right  side  depended  on  the  liver.  (Twelve  leeches  to  the 
left  side  ; two  sinapisms.) 

On  the  12lh,  prostration  more  marked  ; air  of  stupor;  tongue  white,  but  smooth 
and  evincing  a tendency  to  become  dry;  great  thirst;  abdomen  free  from  pain,  and 
tympanitic  ; diarrhoea  more  profuse  than  on  the  preceding  days  ; cough  with  slight 
catarrhal  expectoration  ; respiration  hurried  ; pulse  frequent  and  weak  ; skin 
constantly  hot  and  dry.  (Mucilaginous  mixture,  with  two  grains  of  Kermes, 
Dover’s  powder  ; embrocations  to  the  abdomen  with  oil  of  camomile  ; fomenta- 
tions with  infusion  of  camomile ; six  leeches  behind  each  ear  ; two  blisters  to 
the  thighs.) 

On  the  13th,  vomiting  after  taking  a dose  of  Dover’s  powder  ; mild  delirium 
during  the  night;  tongue  dry  and  white  ; increase  of  the  meteorism  : constant 
and  involuntary  movement  of  the  thumb  of  the  left  hand.  Same  state  in  other 
respects.  (Fomentations  and  embrocations  as  on  the  preceding  days  ; lavement 
of  camomile  with  five  drops  of  essential  oil  of  aniseed  and  twelve  grains  of 
camphor  ; twelve  leeches  over  the  left  side  of  the  chest,  four  over  each  jugular 
vein.) 

On  the  14th,  prostration  still  greater  ; tongue  white,  and  at  the  same  time  dry 
and  encrusted  ; continuance  of  the  meteorism  and  diarrhoea  ; cough  less  ; deep 
sighs  from  time  to  lime  ; pulse  very  frequent,  weak  and  tremulous.  (Watery 
infusion  of  quinquina,  acidulated  with  sulphuric  acid,  sweetened  with  syrup, 
mineral  lemonade,  some  wine.) 

On  the  15th,  night  calm  without  delirium  ; respiration  higher  and  loud  ; pulse 
more  resisting ; commencing  eschar  in  the  sacrum  about  the  breadth  of  the  palm 
of  the  hand.  (Large  blister  over  the  left  side  of  the  chest,  which  still  remains 
dull.) 

On  the  16th,  same  state.  (Frictions  with  camphorated  alcohol.) 

On  the  17tn  and  18th,  the  tongue,  lips,  and  teeth,  were  black  and  encrusted  ; 
abdomen  very  tympanitic  ; diarrhoea  moderated  ; pulse  very  frequent  and  very 
weak.  There  was  added  to  the  prescription  of  the  preceding  days  a potion  made 
of  six  ounces  of  quinquina  and  one  ounce  of  syrup  of  quinquina. 

On  the  19th,  the  patient  no  longer  recognises  the  persons  around  her  ; mild 
delirium;  countenance  very  pale;  tongue  covered  with  black  crusts;  pale 
beneath  them  and  in  the  intervals  between  them  ; tympanitic  state  increasing; 


56 


ANDRAL’S  MEDICAL  CLINIC. 


fourorfive  involuntary  stools  within  the  last  twenty-four  hours.  (Same  prescrip- 
tion.) 

On  the  20th,  eyes  dull,  almost  extinct;  sweat  on  the  face  ; respiration  loud  ; 
pulse  scarcely  perceptible.  She  died  at  eleven  o’clock  in  the  morning. 

Post-mortem,  twenty-two  hours  after  death.  No  emaciation. 

Cranium.  — The  membranes  and  substance  of  brain  not  injected  ; brain  has  its 
ordinary  consistence  ; a little  limpid  serum  at  the  base  of  the  cranium  and  in  the 
spinal  canal. 

Thorax.  — Its  vertical  diameter  very  much  diminished  on  the  right  by  the 
liver,  which  ascends  as  high  as  the  fourth  rib.  The  lung  of  this  side  presents 
but  slight  engorgement  posteriorly.  The  lower  lobe  of  the  left  lung,  on  the  con- 
trary, is  compact,  hard,  impervious  to  air,  in  the  state  of  red  hepatisation.  In 
the  interlobular  fissure  of  the  lung  of  this  side  we  found  a recent  false  membrane 
of  about  a line  in  thickness.  The  heart,  colourless  and  flaccid,  was  proportioned 
to  the  size  of  the  subject.  Its  right  cavities  contained  a coagulum  divested  of 
colouring  matter. 

Abdomen.  — The  stomach  was  moderately  distended  with  gases  and  liquids. 
Its  inner  surface  presented  two  distinct  colours  ; the  splenic  portion  of  a rose 
colour.  This  colour  resided  in  the  mucous  membrane  which  was  a little  puffed  ; 
the  rest  of  the  stomach  was  white. 

The  inner  surface  of  the  small  and  large  intestine  remarkably  white.  In  the 
lower  fourth  of  the  small  intestine  some  rounded  ulcerations  were  found,  of  about 
the  diameter  of  a lentil,  whose  white  edges,  when  cut  perpendicularly,  were 
formed  of  mucous  membrane  slightly  swollen,  and  the  bottom  of  which,  also 
very  white,  exposed  the  fibres' of  the  muscular  layer.  To  the  extent  of  half  a 
foot  above  the  valve,  these  ulcerations  became  confluent,  broader  and  more  irre- 
gular. The  bottom  and  edges  presented  the  same  arrangement.  The  bottom  of 
some  was  covered  by  a soft  layer,  of  a yellowish  grey  colour,  firmly  adhering 
(eschar  of  the  mucous  membrane).  Between  these  ulcerations  were  observed 
two  or  three  elevations,  of  the  size  of  a lentil,  and  white  as  the  rest  of  the  mu- 
cous membrane,  at  the  expense  of  which  they  were  formed.  The  mesenteric 
ganglions  corresponding  to  the  ulcerations  were  red  and  tumefied  ; the  spleen  was 
soft  and  large. 

Residence  in  Paris  for  a little  time  ; prolonged  fatigue  and  watching  ; state 
of  languor  and  general  illness  preceding  the  invasion  of  the  disease,  by  forming 
as  it  were  the  prodrome,  and  being  referable,  as  in  the  preceding  case,  to  an 
exhaustion  of  the  innervation  ; presently  after  symptoms  of  pulmonary  inflam- 
mation, which  seemed  to  yield  to  two  bleedings,  one  local,  and  the  other  gene- 
ral ; at  the  time  of  the  patient’s  admission  to  the  hospital,  and  on  the  following 
days,  a remarkable  air  of  stupor,  insensibility  physical  and  moral;  delirium  at 
intervals  ; rapid  increase  of  prostration  ; dryness  and  at  the  same  time  paleness 
of  the  tongue;  involuntary  stools;  frequency  and  extreme  smallness  of  the 
pulse  ; permanent  delirium  and  carphology  towards  the  termination  ;^such  were 
the  principal  phenomena  observed  in  this  patient.  At  the  commencement,  the 
antiphlogistic  treatment  was  employed;  subsequently,  a treatment  extremely 
tonic  and  stimulant.  At  \\\e  post-mortem,  the  same  lesions  as  in  all  the  preced- 
ing cases ; only  there  was  here  a remarkable  circumstance  ;.  namely,  the  total 
absence  of  redness  or  any  other  unusual  colour,  either  in  the  ulcerations,  or 
around  them. 

Shall  we  connect  with  this  remarkable  absence  of  colour  of  the  intestinal  mu- 
cous membrane,  the  no  less  remarkable  paleness  which  the  tongue  presented 
during  life  ? It  was  not  red  when  it  became  dry,  and  at  a later  period  when  it 
was  covered  with  thick  black  crusts,  it  still  presented  great  paleness  in  the  in- 
tervals between  these  crusts. 

The  nature  of  the  blood  drawn  from  the  vein  is  worthy  of  remark.  We  have 


DISEASES  OF  THE  ABDOMEN. 


57 


seen  that  it  was  almost  entirely  formed  of  very  clear  serum.  What  an  immense 
difference  between  this  serous  blood,  almost  without  fibrin  and  colouring  matter, 
and  that  which  forms  in  the  vessel  in  which  a large  dense  clot  is  received  which 
is  often  covered  by  a huffy  coat  of  greater  or  less  thickness.  Yet  there  was  here 
extensive  inflammation  of  the  lung.  Thus  blood  of  a peculiar  nature,  very  poor 
in  nutritive  and  stimulating  materials,  circulated  in  the  veins  of  this  woman.  Did 
not  this  blood  thus  modified  perform  its  part  in  the  production  of  several  symp- 
toms ? Could  it  not  explain  to  us  the  state  of  the  individual’s  strength  ? Could 
it  not  assist  us  in  foreseeing  the  nature,  form,  and  danger  of  the  phenomena 
which  were  developed  in  consequence  of  the  double  affection  of  the  intestine 
and  the  lungs  ? Must  it  not,  in  a word,  have  influenced  in  some  measure  the 
mode  of  treatment?  On  seeing  the  blood  so  different  from  itself,  whether  in 
different  diseases,  or  in  one  and  the  same  disease,  attacking  individuals  placed, 
by  their  temperament,  their  age,  and  their  mode  of  living,  in  dissimilar  circum- 
stances, how  can  we  refuse  to  admit  that  the  explanation  of  the  fundamental  or 
accidental  symptoms  of  every  disease  should  be  looked  for  in  the  blood  as  well 
as  in  the  solids?  If  the  ancients  often  saw,  in  the  diseases  which  they  called 
malignant  or  putrid  fevers,  a blood  similar  to  that  which  came  from  the  vein  of 
the  woman  who  forms  the  subject  of  this  case,  they  were  right  in  saying,  that 
in  these  diseases  there  is  a state  of  dissolution  of  the  blood.*  But  they  were 
wrong  if  they  made  this  assertion  generally  ; if  they  contended  that  this  solution 
of  the  blood  is  a necessary  element  and  one  that  is  indispensable  in  the  production 
of  these  fevers  ; for  in  many  of  our  cases  the  blood  was  far  from  presenting  such 
a character.  Thus,  in  scurvy,  the  blood  has  been  frequently  seen  completely 
destitute  of  the  property  of  coagulating;  and  very  often  also  it  has  been  found, 
in  this  disease,  as  well  coagulated  as  in  any  other  affection. 

The  pneumonia  was  announced  here  by  symptoms  less  marked  than  in  the 
preceding  case.  The  expectoration  was  constantly  that  of  mere  catarrh,  the 
breathing  appeared  really  embarrassed  only  during  the  last  forty-eight  hours  ; the 
acute  pain  which  the  patient  felt  at  first  in  the  right  side  of  the  chest,  the  dulness 
of  the  chest  over  a great  portion  of  this  side,  owing  to  the  great  enlargement  of 
the  liver,  might  have  led  one  into  error  with  respect  to  the  seat  of  the  pulmonary 
inflammation. 

As  in  most  of  the  other  cases,  the  brain  presented  no  appreciable  lesion,  though 
the  patient  had  considerable  delirium.  The  functions  of  organs  then  may  be 
injured  without  these  organs  themselves  presenting  in  their  texture  any  per- 
ceptible alteration.  It  also  appears  very  difficult  for  us  to  declare  precisely  in 
what  state  the  brain  shall  be  found  in  individuals,  who,  during  the  course  of 
typhoid  fevers,  have  had  delirium  and  other  nervous  symptoms.  Accordingly, 
in  several  individuals  who  presented  these  symptoms,  we  found  in  some,  (and 
that  is  not  the  smallest  number,)  the  brain  and  its  envelopes  perfectly  healthy ; 
in  others  the  cerebral  substance  appears  in  general  more  consistent ; in  a third, 
it  is  injected,  and  studded  with  an  immense  number  of  red  points,  which  are 
the  orifices  of  so  many  small  vessels  ; in  a fourth,  albuminous  concretions  exist 
in  the  sub-arachnoid  cellular  tissue  of  the  upper  surface  of  the  brain,  or  of  it3 
base;  in  a fifth,  the  ventricles  are  filled  with  a more  or  less  considerable  quantity 
of  limpid  serum.  On  the  other  hand,  how  often  have  we  seen  the  ventricles 
contain,  at  least,  an  equal  quantity  of  serum,  in  persons  who  had  died  without 
ever  presenting  the  least  disturbance  in  their  intellectual,  sensorial,  and  loco- 
motive faculties ! 

♦ In  febribus  petechialibus , sanguis  valde  fluidus , serosus  ac  solutus  est.  (Hoffman,  Medic 

edit,  in  quarto,  part  iv,  sect.  i.  chap.  10.) — In  acutus  et  continuis  febribus,  sanguis 

Jluidissimus  comparet,  plane  non  in  coagulum  concrescens.  (Ibid.  chap.  10.)  Grant  has  also 
observed  a similar  state  of  the  blood  in  persons  attacked  with  petechial  fever.  (See  his  work 
on  Fevers.) 


58 


ANDRAL’S  MEDICAL  CLINIC. 


Case  18. — Epistaxis  at  the  commencement — Ataxo-adynamic  symptoms  from  the  first  days 
of  the  disease ; diarrhoea  during  its  entire  course — Leeches;  blisters;  stimulating  antispas- 
modics  (assafoetida,  musk,  etc.) — Death  on  the  1 3th  day — Ulcerations  of  the  small  intestine 
— Healthy  state  of  the  large  intestine — Effusion  of  blood  into  the  tunics  of  the  stomach,  into 
the  muscles  of  the  abdominal  parietes,  into  the  pleurae  and  pericardium. 

A girl,  seventeen  years  old,  was  attacked  on  the  14th  of  July  with  a profuse 
epistaxis,  which  re-appeared  on  the  following  days.  At  the  same  time  there  was 
diarrhoea  and  general  illness.  (Leeches  were  applied  to  the  right  iliac  region.) 

On  the  19th,  face  pale;  the  patient  looks  as  it  were  astounded;  answers  to 
questions  are  painful  and  uncertain  ; tongue  red  and  dry  at  its  apex;  abdomen, 
free  from  pain  and  soft;  continuance  of  the  purging  ; pulse  weak,  not  frequent; 
skin  not  hot ; profuse  epistaxis  on  this  night.  (Barley-water  ; linseed  lavement.) 

On  the  20th,  deglutition  difficult;  stupor  increased.  (Two  blisters  to  the 
legs.) 

On  the  21st,  the  patient  lay  with  slight  retroversion  of  the  head  ; her  eyes, 
which  were  closed,  opened  when  she  was  spoken  to,  but  were  not  fixed  on  any 
object;  she  did  not  answer,  though  she  seemed  to  hear  and  to  comprehend.  She 
was  continually  uncovering  herself,  complaining,  and  uttering,  occasionally, 
piercing  cries;  her  countenance  then  put  on  the  expression  of  the  most  acute 
pain  ; the  chest  was  frequently  raised,  and  the  shoulders  were  thrown  back  by 
a sudden  movement.  The  two  jaws  firmly  closed  the  one  against  the  other,  as 
at  the  commencement  of  tetanus,  prevented  the  longue  from  being  seen.  All 
the  drinks  which  we  tried  to  introduce  into  her  mouth  were  thrown  up  convul- 
sively. Three  or  four  liquid  stools;  pulse  small,  scarcely  frequent;  skin  cool. 
(Two  lavements  of  linseed  meal,  with  twenty  grains  of  assafoetida  in  each,  and 
ten  grains  of  musk.) 

On  the  22d,  profuse  bleeding  from  the  gums  ; in  other  respects  no  perceptible 
change.  (Four  demi-lavements  of  camomile,  with  a scruple  of  assafoetida,  and 
ten  grains  of  musk  in  each  ; two  blisters  to  the  thighs.) 

On  the  23d,  perceptible  improvement;  countenance  more  natural ; answers 
questions  stammeringly  ; attempts  in  vain  to  show  the  tongue,  which  is  smooth 
and  dry.  (Two  more  blisters  beneath  those  applied  the  preceding  day  ; in  other 
respects  the  same  prescription.) 

On  the  24th,  appearance  of  the  face  more  natural ; the  patient  understood  all 
the  questions  very  well ; she  sometimes  answered  them  by  signs,  sometimes  by 
indistinct  words.  The  tongue  was  dry  and  brownish;  the  gums  bled;  deglu- 
tition well  performed  ; the  patient  complained  of  a burning  heat  all  along  the 
pharynx  and  oesophagus  ; pulse  not  frequent ; skin  not  hot.  (The  same  lave- 
ment; acidulated  wash.) 

On  the  25th,  the  patient  seemed  to  have  only  the  intellects  of  a child  seven 
years  old,  and  expressed  herself  so;  the  lower  jaw  was  agitated  by  a tremor 
similar  to  that  which  occurs  in  the  shivering  fit  of  fever;  the  temperature  of  the 
skin  was  raised,  and  the  pulse  had  acquired  some  frequency. 

On  the  26th,  the  state  of  excitement  of  the  preceding  days  was  succeeded  by 
considerable  prostration  ; the  lips  and  tongue  were  covered  with  black  incrus- 
tations ; four  involuntary  liquid  stools  had  taken  place;  the  breathing  was 
hurried,  for  the  first  time  the  pulse  retained  its  frequency.  (Barley  ptisan 
with  gum;  mixture,  with  eight  grains  of  musk;  gargle  of  mel  rosarum  and 
muriatic  acid.) 

In  the  course  of  the  day  the  breathing  became  more  and  more  embarrassed, 
and  the  patient  died  as  it  were  in  a state  of  asphyxia,  at  five  o’clock  in  the 
evening. 

Post-mortem.  Effusion  of  a very  deep  red  liquid  into  the  spinal  canal. 
Copious  effusion  of  red  liquid  into  the  pericardium  and  two  pleurae,  which 
presented  no  trace  of  inflammation.  Lungs  were  engorged  and  crepitated. 


DISEASES  OF  THE  ABDOMEN. 


59 


Large  ecchymosis  between  the  fibres  of  the  muscles  of  the  right  side,  a little 
above  the  pubis. 

The  stomach  distended  with  gases  was  generally  injected  on  its  inner  surface. 
Along  its  great  curvature,  and  over  its  posterior  paries,  there  were  several 
patches  of  a brownish  red  colour,  owing  to  a sanguineous  infiltration  of  the  sub- 
mucous cellular  tissue.  The  small  intestine  was  white  as  far  as  about  two  feet 
above  the  caecum  ; in  this  last  situation,  when  touched  atfirst  externally,  it  was 
hard,  studded,  and  considerably  thickened  in  several  points  : these  latter  corre- 
sponded to  so  many  ulcerations,  the  greyish  bottom  of  which  was  formed  of  the 
laminated  tissue  considerably  thickened.  At  the  distance  of  four  or  five  inches 
above  the  valve,  there  was  observed  but  one  ulceration,  and  that  of  great  size. 

If  we  had  found  in  all  the  dead  bodies  of  the  preceding  patients  morbid  ap- 
pearances as  serious  as  those  presented  by  the  small  intestine  of  this  young  girl, 
we  might  have  easily  established  the  relation  between  the  lesions  discovered  by 
the  autopsy  and  the  symptoms  observed  during  life.  The  ulcerations  were  here 
remarkable  both  for  their  extent  and  for  their  depth  ; there  was  no  trace  of  the 
exantheme  which  had  preceded  them,  and  yet  the  disease  had  commenced  but 
thirteen  days  before.  Profuse  epistaxis  marked  its  onset;  from  the  commence- 
ment the  intestinal  affection  disclosed  itself  by  diarrhoea.  A few  days  after  the 
attack  there  was  already  a very  well  marked  air  of  stupor  : every  day  the  ner- 
vous symptoms  became  more  striking  ; the  tongue,  at  first,  red,  became  dry  and 
black  ; in  the  midst  of  these  numerous  and  serious  phenomena,  we  perceived 
an  entire  absence  of  fever;  the  pulse  acquired  some  frequency,  and  the  tempera- 
ture of  the  skin  became  raised  only  two  days  before  death.  Thus,  in  this  case, 
the  intense  inflammation  with  which  the  digestive  tube  was  attacked,  developed 
itself  and  proceeded  to  ulceration,  without  any  disturbance  taking  place  in  the 
circulation  : it  is  somewhat  difficult  to  believe  that  such  a lesion  could  form 
without  any  pain  having  ever  announced  it  and  without  the  abdomen  having  ever 
become  tympanitic  ; yet  such  was  the  case. 

We  may  remark  how  great  the  tendency  to  hemorrhages  was  in  this  individual. 
The  nasal  mucous  membrane,  the  tissue  of  the  gums,  the  spinal  arachnoid,  the 
two  pleurae,  the  serous  covering  of  the  pericardium,  the  sub-mucous  cellular  tis- 
sue of  the  stomach,  the  intermuscular  cellular  tissue  of  the  abdominal  parietes, 
were  alternately  or  simultaneously  the  seat  of  profuse  sanguineous  exhalations. 

Case  19. — At  the  commencement  slight  continued  fever — Subsequently  ataxo-adynamic 
symptoms,  the  appearance  of  which  coincided  with  epistaxis  — Leeches  and  blisters;  quin- 
quina on  the  last  day  — Death  on  the  seventeenth  day  — Ulceration  in  the  ileum  and  caecum 
— Spleen  large. 

A man,  forty-five  years  of  age,  presented  for  about  eleven  days  symptoms  of 
slight  continued  fever  ; he  had  no  purging  ; he  had  been  treated  with  simple 
diluents.  On  the  eleventh  day  (31st  October)  he  had  profuse  epistaxis.  On 
this  same  day  his  pulse  became  more  frequent,  his  tongue  became  red  and  dry, 
the  abdomen  became  tympanitic.  (Twenty  leeches  to  the  anus.) 

On  the  12th  day,  the  pulse,  which  was  full  enough  on  the  preceding  days, 
was  remarkably  small ; the  skin  was  free  from  heat;  the  tongue  was  brown. 
Thus,  notwithstanding  the  bleeding  at  the  anus,  the  state  of  the  patient  became 
worse.  The  most  pressing  indication  seemed  to  be  to  recruit  the  strength.  A 
blister  was  therefore  applied  to  one  of  the  legs.  Its  employment  was  so  much 
the  more  indicated,  as  no  reaction  took  place  on  the  skin.  The  drink  adminis- 
tered was  barley  ptisan,  sweetened  with  honey.  The  patient  raved  all  the  night. 
On  the  morning  of  the  13th,  his  ideas  were  not  yet  clear;  numerous  petechiae 
covered  the  skin  of  the  neck  and  abdomen  ; the  constipation  continued.  (Bar- 
ley ptisan  ; mineral  lemonade  ; lavement  of  camomile.) 

On  the  14th  and  15th  days,  the  state  of  the  patient  was  worse  : he  raved 


60 


ANDRAL’S  MEDICAL  CLINIC. 


almost  continually  ; the  features  became  sharpened  ; tongue  still  brown  ; abdo- 
men tympanitic  and  free  from  pain  ; pulse  scarcely  felt ; skin  cold.  (The  same 
drinks  were  continued  ; the  extremities  were  rubbed  with  stimulating  liniments.) 

On  the  16th  day  the  prostration  was  extreme  ; the  patient  was  aroused  with 
difficulty  from  the  state  of  stupor,  and  pronounced,  stammeringly,  some  unintel- 
ligible words  ; the  petechise  were  no  longer  so  numerous.  (Two  cups  of  the 
watery  infusion  of  quinquina,  one  scruple  of  camphor  in  a camomile  lavement.) 

On  the  17th  day  the  patient  was  dying;  the  tympanitis  was  very  considera- 
ble. He  died  in  the  night. 

Post-mortem.  Lungs  very  much  engorged  ; crepitated  but  little ; their  tissue 
was  easily  torn. 

The  stomach  was  distended  with  gases  and  liquids  ; its  inner  surface  was 
very  white,  except  at  the  great  cul-de-sac,  where  there  existed  two  small  red 
spots,  each  being,  at  most,  the  size  of  a five  sous  piece.  These  spots  belonged 
to  the  mucous  membrane,  which  appeared  every  where  else  perfectly  healthy. 

The  small  intestine,  including  the  duodenum,  contained  a great  quantityof 
yellow  bile,  which  coloured  the  valves.  Its  inner  surface,  when  washed,  was 
very  white  to  about  a foot  above  the  ileo-caecal  valve.  At  this  part  there  were 
found  ulcerations,  whose  edges  were  raised  and  brown,  and  the  bottom  of  which, 
being  white,  was  formed  of  laminated  tissue,  now  thickened.  In  the  first  eight 
inches  we  counted  but  five  or  six,  each  about  the  size  of  a twenty  sous  piece ; 
between  them  the  mucous  membrane  was  white ; in  the  four  last  inches  these 
ulcerations  were  more  numerous ; the  mucous  membrane,  red  in  the  intervals 
between  them,  was  entirely  destroyed  on  the  upper  surface  of  the  valve. 

The  caecum  was  studded  with  a great  number  of  small  ulcers,  all  equal  in  size 
and  capable  of  containing  a small  lentil.  The  mucous  membrane,  which  formed 
the  edges,  and  the  laminated  tissue  which  formed  the  bottom  of  them,  retained 
their  natural  thickness.  Between  them  the  caecum  presented  a red  colour,  which 
resided  in  the  mucous  membrane. 

The  remainder  of  the  large  intestine,  which  was  filled  with  softened  faeces, 
was  very  white.  The  spleen  was  very  large. 

The  preceding  case  presents  to  us  a disease  which,  mild  up  to  its  eleventh 
day,  suddenly  assumed  a serious  character,  at  the  same  time  that  profuse  nasal 
hemorrhage  showed  itself.  The  application  of  leeches  did  not  moderate  these 
symptoms,  the  rapid  prostration  of  strength  principally  engaged  our  attention ; 
recourse  wras  had  to  blistering,  but  in  vain.  On  the  13th  day,  some  petechise 
appeared,  and  their  existence  at  a time  when  the  patient  had  as  yet  taken  but 
some  diluent  drinks,  belies  the  assertion  of  De  Ilaen,  who  lays  it  down  as  a 
general  principle,  that  the  petechise  which  appear  in  typhoid  fevers,  are  always 
the  result  of  the  unseasonable  employment  of  emetics  and  purgatives.  The  de- 
lirium became  constant.  Still  no  other  tonic  was  employed  but  mineral  lemon- 
ade ; an  attempt  was  made  to  excite  the  action  of  the  skin  by  stimulating  frictions. 
The  adynamic  state  soon  attained  the  last  degree,  and  the  patient  dies  after  having 
taken  quinquina  only  twenty-four  hours  before  death. 

At  the  post-mortem , the  brain  was  found  to  be  intact,  though  complete  deli- 
rium had  existed  ; the  gastric  mucous  membrane  was  healthy,  though  the  tongue 
had  been  dry  and  black,  and,  as  in  all  the  preceding  cases,  there  was  serious 
lesion  of  the  small  intestine  : nor  was  there  found  in  the  latter  any  trace  of  ex- 
antheme,  but  merely  ulcerations  ; there  was  some  also  in  the  caecum,  and  yet  the 
patient  had  never  had  purging. 

We  may  remark  the  very  great  quantity  of  bile  which  filled  the  intestine. 
This  bile  particularly  engaged  the  attention  of  Stall,  and  this  circumstance  would 
have  had  great  weight  with  him  in  determining  the  nature  of  the  disease  and  its 
treatment. 


DISEASES  OF  THE  ABDOMEN. 


61 


Case  20.  — Ataxo-adynamic  symptoms — Daily  exacerbations,  resembling  the  accessions  of 
intermittent  fever  — Parotitis — Varioloid  eruption  on  the  epigastrium  — Leeches ; blisters  ; 
wine;  quinquina  in  drinks  and  in  lavement  — Death  on  the  19th  day  — Ulcerations  to- 
wards the  extremity  of  the  small  intestine  — Large  intestine  healthy — Injection  of  the  gas- 
tric mucous  membrane  — Spleen  of  the  ordinary  size. 

A carpenter,  thirty-six  years  of  age,  of  a very  strong  constitution,  was  brought 
to  the  Charite,  on  the  24th  of  June,  in  a state  of  delirium,  which  prevented  us 
from  learning  from  him  the  commencement  and  cause  of  the  disease.  Those 
who  brought  him  stated  that  he  was  ill  for  the  last  nine  days. 

June  25th.  Lies  on  his  back,  cheeks  flushed,  eyes  half-shut,  mouth  open, 
lips  black  and  dry,  tongue  black,  dry,  cleft ; pain  in  the  epigastrium  and  in  the 
csecal  region  on  pressure,  constipation  ; pulse  weak  and  very  frequent,  skin  dry 
and  hot;  eruption  on  the  abdomen,  principally  at  the  epigastrium,  of  pimples 
with  a red  base,  the  summit  of  which  was  surmounted  with  a large  vesicle  still 
transparent  in  some,  opaque  and  containing  real  pus  in  others.  The  patient 
complained  very  much  ; he  comprehended  with  difficulty  the  questions  put  to 
him  : he  seemed  to  have  entirely  lost  the  recollection  of  what  was  past. 
(Fifteen  leeches  to  the  anus,  a blister  to  one  thigh,  decoction  of  barley,  mineral 
lemonade.) 

In  the  course  of  the  day  he  became  completely  delirious.  On  the  morning 
of  the  26th,  the  tongue  was  more  moist  ; one  stool,  same  state  in  other  respects. 
(Four  leeches  on  each  side  of  the  neck.) 

On  the  27th,  sweat  on  the  face  and  upper  extremities;  no  change  in  other 
respects.  (Barley  ptisan  ; mineral  lemonade,  decoction  of  polygala,  some 
wine.) 

On  the  28th,  very  painful  swelling  on  the  right  parotid  gland,  tongue  black, 
no  stool,  abdomen  soft,  appearing  insensible  to  pressure,  the  pustules  of  the 
epigastrium  were  all  white,  and  varioloid  ; the  pulse  was  small  and  frequent ; 
the  patient  was  in  a state  of  mild,  continued  delirium.  (Same  prescription.) 

On  the  29th,  we  found  the  face,  neck,  and  upper  extremities,  covered  with 
sweat,  as  on  the  27th. 

On  the  30th,  the  delirium  still  continued,  the  prostration  increased,  the 
pulse,  very  frequent,  and  extremely  small,  the  skin  burning  hot;  the  tongue 
remained  dry  and  brown,  the  abdomen  was  soft,  constipation  was  obstinate  ; 
the  parotid  gland  became  larger.  (A  lavement  of  quinquina  was  added  to  the 
prescription  of  the  preceding  days.)  At  four  o’clock  in  the  evening,  the  eye 
was  extinct,  half  shut ; subsultus  tendinum  very  frequent,  carphology,  continual 
muttering. 

On  the  morning  of  the  1st  of  July,  the  face  had  a more  natural  expression  ; 
the  eye  less  dull,  opened  from  time  to  time  ; the  patient  groaned  at  intervals  ; 
he  made  an  effort  to  answer  questions,  but  could  not  articulate  ; he  showed  his 
tongue  when  asked,  with  sufficient  ease  ; it  was  dry,  black,  and  marked  with 
fissures:  no  stool.  Parotid  gland  larger  and  harder.  (Same  prescription.)  At 
two  o’clock  in  the  afternoon,  face  cadaverous,  passive  dilatation  of  the  buccina- 
tors at  each  expiration,  constant  muttering,  pulse  very  weak,  and  too  frequent 
to  admit  of  being  counted. 

July  2d.  This  state  of  agony  continued.  Watery  infusion  of  quinquina, 
barley,  mineral  lemonade,  two  sinapisms.) 

We  thought  that  the  patient  would  die  in  the  course  of  the  day  ; yet  what 
was  our  astonishment  when,  on  the  morning  of  the  3d,  we  found  a sensible 
amendment  ! in  particular  the  appearance  of  the  face  was  better  ; the  patient 
understood  questions,  but  did  not  answer  them  ; he  put  out  his  tongue  slowly 
and  with  difficulty  : it  was  moist,  clammy,  but  black.  The  teeth  were  cleaned, 
the  skin  was  without  heat,  the  pulse  weak  ; state  of  the  parotid  gland  the 
6 


62 


ANDIiAL’S  MEDICAL  CLINIC. 


same ; a great  part  of  the  pustules  of  the  epigastrium  dried.  (Same  pre- 
scription.) 

At  four  o’clock  in  the  evening,  the  face  took  on  again  a cadaverous  aspect ; 
the  patient  no  longer  seemed  to  hear  questions  as  in  the  morning  ; the  eyelid 
was  depressed  one  half  over  the  eye  which  was  nearly  extinct : the  buccinator 
muscles  were  dilated,  as  on  the  preceding  day. 

On  the  morning  of  the  3d  of  July,  another  amendment  took  place  ; the 
patient  heard,  and  for  the  first  time  was  able  to  articulate  some  words  connectedly  ; 
the  tongue  was  moist  and  clean,  the  abdomen  flat  and  free  from  pain ; had  one 
stool  within  the  last  forty-eight  hours,  The  parotid  gland  was  very  large,  a 
great  quantity  of  pus  flowed  through  the  ear.  (Same  prescription.) 

At  four  in  the  afternoon,  the  amendment  of  the  morning  had  disappeared ; a 
state  similar  to  that  of  the  preceding  day  at  the  same  hour  had  succeeded  it. 

The  patient  died  on  the  4th,  at  7 o’clock,  in  the  morning. 

Post-mortem , twenty-five  hours  after  death.  Considerable  emaciation  ; mus- 
cles blackish  ; parotid  projecting  very  much  on  the  side  of  the  head  and 
neck.  A great  quantity  of  sanious  and  greyish  liquid  separated  the  granula- 
tions of  the  gland.  Immediately  below  the  pinna  auriculae  a small  abscess  was 
found  ; through  which  a probe  was  easily  passed  as  far  as  the  external  auditory 
meatus. 

Cranium . — Neither  the  brain  nor  its  membranes  presented  any  thing  remark- 
able, a little  serum  was  found  in  the  ventricles  ; the  veins  entering  into  the  supe- 
rior longitudinal  sinus  contained  some  bubbles  of  air  in  considerable  quantity, 
probably  the  result  of  decomposition. 

Chest. — The  laminated  tissue  of  the  anterior  mediastinum  was  swelled  with 
gases,  which  gave  it  a great  resemblance  to  the  external  surface  of  the  lungs  of 
reptiles  ; the  pericardium  contained  a perceptible  quantity  of  yellow  serum  ; 
heart  a little  flaccid  and  empty  ; lungs  healthy  ; that  of  the  right  side  adhered 
to  the  ribs  by  old  cellular  bands  ; the  bronchi  of  this  side  were  red. 

Abdomen.  — The  stomach  was  a little  contracted  on  itself  in  its  pyloric  por- 
tion ; the  small  intestines  were  of  their  natural  size  ; the  large  intestine  presented 
contractions  in  different  points  of  its  extent : the  inner  surface  of  the  stomach 
wras  perfectly  white  over  all  its  splenic  portion  ; but  the  pyloric  portion  was 
very  much  injected.  The  inner  surface  of  the  duodenum,  as  well  as  that  of 
the  upper  five-sixths  of  the  small  intestine,  was  lined  with  mucus  mixed  with 
yellow  bile.  All  this  portion  of  the  intestine  was  in  other  respects  very  healthy, 
white  and  transparent ; in  some  points  only  there  existed  a slight  injection  of 
the  sub-mucous  capillary  network.  In  the  lower  six  of  the  small  intestine, 
the  mucous  membrane  presented  five  or  six  large  ulcerations  with  irregu- 
lar edges,  the  bottom  of  which,  being  of  a reddish  colour,  was  formed  of  the  ex- 
posed muscular  tunic.  Between  them  the  mucous  membrane  was  but  slightly 
injected;  the  corresponding  mesenteric  glands  were  of  a brownish  red  colour 
and  swollen.  The  large  intestine,  filled  with  consistent  and  yellowish  matters, 
was  perfectly  white. 

The  course  of  this  disease  well  merits  our  attention.  No  change  took  place, 
whether  favourably  or  unfavourably,  for  the  first  few  days  ; and  considering  the 
very  serious  symptoms  that  existed,  it  was  somewhat  remarkable  that  the  dis- 
ease remained  stationary  ; but  then  a sort  of  exacerbation  took  place  every  even- 
ing, during  which  a real  paroxysm  ( agonie ) was  observed.  Was  it  not  a sort 
of  malignant  remittent  fever,  and  would  not  the  quinquina,  given  plenis  mani- 
bust  as  Pigner  used  to  say,  before  the  return  of  the  exacerbation,  have  pre- 
vented it  ? It  was  after  the  fourth  exacerbation  that  the  patient  died  ; but  it  is 
deserving  of  notice  that  death  did  not  supervene  till  morning,  the  period  when 
the  immediately  mortal  symptoms  of  the  afternoon  used  to  cease. 


DISEASES  OF  THE  ABDOMEN. 


63 


It  is  particularly  on  the  3d  of  July,  that  a dose  of  quinquina  should  have  been 
given  with  the  intent  just  now  stated  ; for  then  the  tongue  presented  nearly  its 
natural  appearance,  and  there  was  very  little  fever. 

The  enlargement  of  the  parotid  gland  must  have  only  aggravated  the  state  of 
the  patient. 

Partial  sweats  appeared  unattended  by  any  advantage  on  the  12th  and  14th  day. 
An  eruption  similar  to  that  which  covered  the  epigastrium  is  not  a common 
phenomenon  in  fever ; it  seemed  to  exercise  no  influence  on  the  progress  of  the 
disease. 

The  delirium  could  not  be  accounted  for  by  any  lesion  of  the  brain  or  its 
membranes. 

The  stomach  itself  presented  but  a slight  degree  of  inflammation  ; such  as  is 
observed  in  several  persons,  who  have  had  no  ataxic  or  adynamic  symptoms, 
and  probably  whose  tongue  never  was  either  dry  or  black. 

The  lesion  of  the  small  intestine,  always  of  the  same  nature  as  that  presented 
in  the  other  cases,  is  the  only  thing  remaining  to  account  for  all  the  symptoms. 

We  may  remark,  that  here  also  an  obstinate  constipation  coincided  with  the 
healthy  state  of  the  intestine. 

Case  21. — Stupor  and  deafness  from  the  very  commencement — Natural  state  of  the  tongue 
in  the  midst  of  adynamic  symptoms — Sudden  disappearance  of  the  deafness — Paralysis  of 
the  bladder  ; gangrene  of  the  penis  and  sacrum — Leeches  to  the  anus ; blisters ; wine  ; 
quinquina  ; camphor — Death  on  the  22d  day — Ulcerations  at  the  extremity  of  the  small 
intestine  and  caecum — Brown  colour  and  softening  of  the  gastric  mucous  membrane — Brain 
dotted  with  red  points — Pneumonia — Spleen  not  much  enlarged. 

A man,  twenty-seven  years  of  age,  of  delicate  constitution,  felt,  on  the  28th 
of  October,  general  illness,  and  without  any  known  cause.  On  the  30th  he  had 
deafness  and  fever,  and  continued  in  the  same  state  up  to  November  2d.  He 
then  entered  the  Charite,  and  twenty  leeches  were  applied  to  the  anus  on  the 
morning  of  the  3d.  On  the  4th  the  fever  was  as  intense  as  on  the  preceding 
day  ; deafness  very  great ; tongue  moist  and  red ; abdomen  free  from  pain  ; 
stools  natural  ; countenance  has  an  air  of  great  stupor  ; movements  slow  and 
painful.  These  last  symptoms,  as  also  the  deafness,  announced  the  commence- 
ment of  ataxo-adynamic  fever.  (Skin  was  rubbed  with  volatile  liniment ; a 
lavement  of  camomile,  with  camphor,  was  prescribed.)  The  state  of  the  patient 
remained  nearly  the  same  from  the  3d  to  the  6th.  (Two  blisters  were  applied 
to  the  legs.) 

On  the  9th  (the  eleventh  day  of  the  disease),  the  deafness  disappeared  all  at 
once;  but  in  the  course  of  the  day  the  bladder  was  struck  with  paralysis  ; a 
large  tumour,  formed  by  this  viscus,  filled  with  urine,  arose  above  the  pubis  ; 
the  patient  was  sounded. 

On  the  10th  of  November  the  paralysis  still  continued  ; the  debility  was  in- 
creased. The  patient  was  plunged  into  a state  of  stupor,  from  which  it  was 
difficult  to  rouse  him;  the  tongue  retained  its  moisture,  and  the  pulse  its  fre- 
quency. (Lemonade  with  wine,  lavement  with  camphorated  camomile,  friction 
with  volatile  liniment  and  cantharides.) 

On  the  11th,  the  prepuce,  irritated  probably  by  the  introduction  of  the  sound, 
was  attacked  with  gangrene ; the  skin  of  the  sacrum  presented  a brownish  red 
colour;  the  prostration  of  the  strength  was  increased;  the  patient  answered 
questions  stammeringly  ; tongue  dry  and  brown  ; pulse  very  weak.  (Two 
glasses  of  aqueous  infusion  of  quinquina  were  added  to  the  prescription  of  the 
preceding  day.) 

On  the  12th  diarrhoea  came  on. 

On  the  13th  symptoms  of  pneumonia  manifested  themselves  ; respiration  fre- 
quent, short,  and  painful  ; patient  coughed  very  much  without  expectorating  ; 


64 


ANDRAL’S  MEDICAL  CLINIC. 


by  percussion  we  detected  a dull  sound  on  the  inferior  and  lateral  part  of  the 
left  side  of  the  chest;  the  eschar  of  the  penis  had  extended  ; the  skin  of  the 
sacrum  was  black  ; the  strength  became  more  and  mote  prostrated  ; the  purging 
continued.  (Same  prescription,  and  also  a blister  to  the  left  side.) 

From  the  14th  to  the  18th  of  November,  the  day  on  which  he  died,  and  which 
was  the  twenty-second  day  of  his  illness,  this  person  was  in  a stale  of  continual 
delirium  ; the  dyspnosa  increased  ; tongue  alternately  dry  and  moist,  brown  and 
a bright  red  : the  purging  continued  ; the  paralysis  of  the  bladder  ceased  ; the 
eschar  of  the  penis  did  not  extend  ; the  eschar  of  the  sacrum,  having  been 
detached,  left  in  its  place  a large  ulcer  with  a greyish  bottom.  The  patient  died 
in  a state  of  extreme  dyspnoea.  (The  same  treatment  was  continued  to  the 
end.) 

Post-mortem.,  forty-eight  hours  after  death.  The  brain,  which  was  of  the 
natural  consistence,  was  dotted  with  a great  number  of  red  points.  Two  tea- 
spoonsful  of  limpid  serum  were  found  in  each  of  the  lateral  ventricles.  The 
membranes  were  a little  injected. 

The  heart  was  pale  and  empty.  The  lower  lobe  of  the  left  lung,  of  a brownish 
red  colour,  was  no  longer  pervious  to  air.  Its  tissue,  being  very  soft,  was  torn 
like  that  of  the  spleen.  The  upper  lobe  of  this  lung,  and  the  entire  of  the  right 
lung,  were  engorged  with  an  enormous  quantity  of  bloody  serum. 

The  stomach  was  distended  with  gases.  The  mucous  membrane,  in  the  great 
cul-de-sac,  presented  a brownish  colour,  and  was  very  soft.  The  mucous 
creptae  of  the  duodenum  were  very  much  enlarged.  The  small  intestine  con- 
tained a great  quantity  of  yellow  bile.  Slight  submucous  injection  was  seen  in 
it;  the  mucous  membrane  itself  was  intact.  But  at  the  distance  of  about  half  a 
foot  above  the  caecum,  the  inner  surface  of  the  intestine  presented  at  first  some 
isolated  brown  spots  : lower  down  it  was  uniformly  brownish.  This  colour 
resided  in  the  thickened  and  softened  mucous  membrane.  In  this  same  space 
five  small  ulcerations  were  found  the  size  of  a five  sous  piece,  the  bottom  of 
which,  being  whitish,  was  formed  by  the  laminated  tissue,  which  was  scarcely 
thickened.  The  inner  surface  of  the  caecum,  and  of  the  entire  colon,  presented 
a slight  injection  of  the  mucous  membrane  and  of  the  subjacent  laminated  tissue. 
Not  far  from  the  caecal  valve  we  observed  a small  isolated  ulceration  similar  to 
that  of  the  small  intestine.  The  mesenteric  glands  were  brown  arid  tumefied. 

Spleen  not  very  large.  The  gangrene  of  the  penis  occupied  only  the  prepuce. 
On  the  sacrum  the  skin  was  destroyed,  in  height,  from  the  coccyx  to  the  level 
of  the  first  lumbar  vertebrae  ; and  in  breadth,  over  the  entire  extent  of  the  trans- 
verse diameter  of  the  sacrum.  This  bone  was  very  much  exposed.  At  the 
bottom  of  this  large  ulcer  we  observed  a black  detritus,  whence  an  infectious 
odour  was  given  off ; all  around  the  skin  was  detached  to  the  extent  at  least  of 
three  or  four  inches. 

Here  it  is  only  from  the  site  of  the  ulcerations  that  we  can  suppose  that  they 
had  been  preceded  by  an  exanthematous  engorgement  of  the  follicles  ; they  were 
small,  and  no  longer  retained  the  form  of  Peyer’s  patches,  but  the  mucous  mem- 
brane surrounding  them  was  more  altered  than  in  the  greater  number  of  the 
preceding  cases.  The  same  may  be  said  of  the  mucous  membrane  of  a part  of 
the  stomach.  The  injection  of  the  brain  was  here  proportioned  to  the  intense 
delirium  which  existed  towards  the  latter  period  ; but  in  how  many  cases  have 
we  not  found  a similar  state  of  delirium  without  finding  in  the  brain  any  trace 
of  sanguineous  congestion  ? 

In  this  patient  there  were  many  other  causes  of  disease  and  death.  The  ex- 
tensive ulcer  of  the  sucrum,  the  hepatisation  of  a great  part  of  the  left  lung,  the 
gangrenous  inflammation  of  the  prepuce,  were  so  many  circumstances  which 
must  considerably  increase  the  danger  of  the  intestinal  affection.  Is  it  not  also 
a remarkable  circumstance,  that  the  slight  irritation  occasioned  by  the  introduc- 


DISEASES  OF  THE  ABDOMEN. 


65 


tion  of  the  sound  into  the  bladder  was  sufficient,  in  this  case,  rapidly  to  produce 
gangrene  of  a part  of  the  penis  ? Lying  on  the  back,  also,  and  that  not  for  a 
very  long  time,  sufficed  to  produce  gangrene  of  the  skin  of  the  sacrum,  and 
to  cause  an  extensive  ulcer  to  succeed  the  falling  of  the  eschar.  Undoubtedly, 
such  gangrenes  cannot  be  accounted  for  by  the  intensity  of  the  local  irritation  ; 
they  suppose  a disposition  altogether  peculiar,  similar  to  that  which,  in  conse- 
quence of  the  slightest  local  lesion,  occasions,  in  certain  individuals,  a sudden 
prostration,  and  all  the  phenomena  indicative  of  this  prostration.  Is  it  not 
a similar  disposition  which  is  produced  in  us,  when  certain  poisons,  called  sep- 
tic, are  introduced  into  the  torrent  of  the  circulation  ? The  carbuncles  ( charbons ) 
developed  in  this  last  case  become,  as  it  were,  the  anatomical  character  of  the 
disease  ; but  it  is  very  evident  that,  far  from  causing  it,  they  are  themselves 
but  an  effect. 

The  nervous  symptoms  appeared  here  almost  from  the  very  commencement 
of  the  disease.  The  deafness,  in  particular,  showed  itself  very  early  ; it  was 
one  of  the  first  phenomena  which  could  indicate  the  development  of  a severe 
disease.  After  having  lasted  for  four  days,  this  deafness  disappeared  all  at  once, 
and  at  the  same  time  the  bladder  became  paralysed  ; at  the  same  time,  also,  the 
parts  of  the  skin  which  had  been  irritated  began  to  become  gangrenous.  It  was 
in  the  midst  of  these  phenomena,  which  seem  to  indicate  a depression  of  the 
strength,  that  the  signs  of  pulmonary  inflammation  appeared.  Why,  in  such  a 
state,  did  the  tongue,  by  a sort  of  exception  to  the  law  which  we  were  entitled 
to  deduce  from  the  preceding  facts,  remain  almost  constantly  in  a condition 
nearly  natural?  To  meet  all  these  symptoms,  was  an  antiphlogistic  treatment 
indicated  ? I do  no  not  think  it ; for  we  even  see  that  the  leeches  applied  to  the 
anus  were  not  followed  by  any  beneficial  result : we  shall  not  say  that  they 
caused  the  prostration ; but  we  shall  only  remark,  that  the  day  after  their  ap- 
plication the  deafness  had  increased  as  well  as  the  stupor  and  difficulty  of 
moving  ; the  loss  of  blood  then  had  not  at  least  any  favourable  influence. 
There  was  no  epistaxis  in  this  case,  as  in  several  of  the  preceding  cases.  Neither 
do  we  see  that  the  cutaneous  revulsives  were  of  any  benefit. 

Case  22. — Diarrhoea  at  first ; subsequently  fever,  dryness  and  redness  of  the  tongue  ; intermit- 
tent delirium  ; coma — Blisters  ; diluent  drinks  ; quinquina  on  the  last  day — Death  on  the 
thirtieth  day  ; ulceration  at  the  extremity  of  the  small  intestine  ; stomach. healthy  ; pneu- 
monia ; spleen  large. 

A mason,  sixteen  years  old,  of  delicate  health,  had  been  affected  with  purging 
for  about  three  weeks,  when  he  entered  the  hospital  (September  4th).  He  had 
been  confined  to  his  bed  for  several  days.  He  observed  strict  regimen,  and  drank 
barley  water.  We  found  him  in  the  following  state  : — 

Countenance  somewhat  cast  down  ; listlessness;  answers  slow  ; tongue  white, 
a little  dry  and  red  at  the  apex;  anorexia,  moderate  thirst;  mouth  clammy; 
abdomen  free  from  pain,  but  distended  with  gas  ; several  liquid  stools  in  the 
twenty-four  hours,  pulse  frequent,  and  ofordinary  strength  ; skin  hot.  (Rice  water 
with  syrup;  emollient  lavement ; broth.)  The  patient  went  to  stool  several  times. 
He  raved  during  the  night. 

On  the  morning  of  the  6th,  the  tongue  was  red  and  a little  dry,  great  thirst, 
abdomen  always  free  from  pain,  and  distended  with  gas  ; same  state  of  the  pulse 
and  skin.  The  delirium  reappeared  at  night. 

7th,  ihe  same  state.  (Two  blisters  to  the  thighs.)  They  prevented  not  the 
delirium  from  being  very  violent  in  the  night;  five  liquid  very  copious  stools. 

8th,  drowsiness,  but  intellects  perfect ; emaciation  of  the  face,  features  very 
much  altered  ; continuance  of  the  purging,  pulse  small,  more  frequent ; skin 
not  hot.  (Blister  over  the  abdomen  ; drinks,  and  emollient  lavements  ; a little 
broth.) 


6* 


66 


ANDUAL’S  MEDICAL  CLINIC. 


In  the  evening  and  all  the  night  the  patient  still  raved. 

9th,  the  eyes  constantly  closed  ; the  patient,  however,  opened  them  when  he 
was  spoken  to.  His  answers  were  slow  and  uncertain  ; features  still  more  altered. 
Tongue  dry,  of  a bright  red  colour  at  its  apex  ; pulse  small,  moderately  frequent ; 
skin  not  hot ; the  surface  of  the  abdomen  to  which  the  blister  had  been  applied  of 
a pale  colour.  (Decoction  of  rice  ; the  following  mixture  : — 

Infusion  of  orange  leaves  . . . four  ourtces. 

Mint  water  . . . . • one  ounce. 

Diascordium  .....  one  drachm  ( gros ). 

Soft  extract  of  kina  ....  half  a drachm  (gros). 

Syrup  of  violet  .....  one  ounce.) 

The  delirium  returned  in  the  night. 

10th,  face  cadaverous  ; answers  slow,  but  accurate  ; articulation  embarrassed, 
tongue  dry  ; lips  black  ; purging  less  ; respiration  accelerated  and  attended  with 
sighs  ; pulse  small,  skin  hotter  than  the  day  before  ; patient  still  strong  enough  to 
sit  up  ; he  died  at  six  in  the  evening. 

Post-mortem, , fourteen  hours  after  death.  — A considerable  quantity  of  limpid 
serum  at  the  base  of  the  cranium  ; none  in  the  ventricles.  Nothing  else  remark- 
able in  the  nervous  apparatus. 

The  lower  lobe  of  the  left  lung  in  a state  of  red  hepatisation.  This  same  lobe 
presented  posteriorly  some  blackish  spots,  a sort  of  ecchy  mosis  which  existed  only 
on  the  surface  of  the  viscus. 

The  stomach  was  white  through  its  entire  extent,  as  well  as  the  two  upper 
thirds  of  the  small  intestine.  The  upper  part  of  the  inferior  third  was  injected, 
and  presented  here  and  there  patches  of  a redder  colour.  Lower  down  we 
observed  numerous  ulcerations  with  raised  and  rounded  edges.  The  smallest 
might  have  admitted  about  the  head  of  an  ordinary  pin,  the  largest  nearly  equalled 
the  breadth  of  a thirty-sous  piece  ; the  laminated  tissue  which  formed  the  bottom 
of  them  was  considerably  thickened,  being  of  a dark  red  in  some,  and  presenting 
in  others  a brownish  grey  tint,  which  seemed  the  result  of  gangrene.  These 
ulcerations  were  closer  together  and  more  extensive,  according  as  they  were 
observed  nearer  to  the  ileo-caecal  valve.  The  portions  of  mucous  membrane 
separating  them  were  injected.  The  inner  surface  of  the  caecum  presented  a 
deep  livid  red  tint.  The  mucous  membrane  of  the  colon,  through  its  entire 
extent,  and  that  of  the  rectum,  were  also  injected,  and  presented  here  and  there 
patches  of  a redder  colour.  The  spleen  was  very  large  and  very  dense. 

Signs  of  intestinal  irritation  marked  the  commencement  of  this  disease  ; the 
diarrhoea  continued  a long  time  without  being  accompanied  by  any  serious 
symptom.  The  lesion  of  the  digestive  passages  ultimately  reacted  on  the  rest 
of  the  economy,  and  then  the  symptoms  of  typhoid  fever  appeared.  The  altera- 
tion presented  by  the  intestine  after  death  was  similar,  in  its  nature  and  site, 
to  that  which  we  found  in  all  the  preceding  cases.  In  all,  this  alteration  differed 
only  in  intensity;  and  what  cannot  be  too  carefully  observed  is,  that  it  is  always 
the  intensity  of  the  alteration  which  decides  the  intensity  of  the  symptoms. 
Here  again,  as  in  many  other  cases,  the  redness  and  dryness  of  the  tongue  are 
not  explained  by  the  state  of  the  stomach,  which  was  found  to  be  perfectly 
healthy. 

When  the  patient  entered  the  Charite  he  appeared  to  be  already  in  a state  of 
great  exhaustion  ; he  became  weaker  and  weaker,  and  after  having  presented 
some  delirium  at  intervals,  he  fell  into  a state  of  coma,  in  which  he  died. 
The  examination  of  the  encephalon  did  not  account  for  these  cerebral  symp- 
toms. 

Whilst,  on  the  part  of  the  nervous  system,  there  had  been  functional  disturb- 
ances, without  any  disturbances,  anatomically  appreciable,  in  the  organs  of  in- 
nervation ; there  was,  on  the  contrary,  on  the  part  of  the  respiratory  passages,  a 


DISEASES  OF  THE  ABDOMEN. 


67 


serious  lesion  of  the  organ,  without  there  having  been  during  life  any  disturbance 
of  its  functions ; it  was  only  some  hours  before  death  that  any  difficulty  of 
breathing  was  observed. 

The  emollient  treatment,  exclusively  followed  during  the  commencement,  did 
not  prevent  the  disease  from  proceeding,  neither  were  the  revulsives  of  any  use  : 
no  benefit  was  derived  from  the  tonics,  employed  only  forty-eight  hours  before 
death. 

Case  23. — Diarrhoea  at  the  commencement — Subsequently  fever,  and  adynamic  symptoms; 
delirium  combated  by  leeches  to  the  mastoid  processes — Appearance  of  amendment  after 
tonic  treatment ; death  towards  the  30th  day  by  intestinal  hemorrhage — Ulcerations  of  the 
extremity  of  the  small  intestine  and  caecum. 

A sawyer,  twenty-eight  years  of  age,  had  profuse  diarrhcea  for  three  weeks, 
when  he  entered  the  Charite  on  the  21st  of  November.  He  was  then  in  a 
state  of  great  debility ; the  tongue  was  very  dry  ; intellects  somewhat  dull ; 
pulse  frequent  and  compressible  ; skin  hot;  some  petechial  spots  scattered  over 
the  epigastrium;  an  air  of  stupor  in  the  face.  (Barley  ptisan  ; strict  regimen.) 

On  the  following  days  the  prostration  increased,  the  spots  became  more  nu- 
merous, the  alvine  evacuations  began  to  be  involuntary  ; some  delirium  super- 
vened, which  was  met  by  the  application  of  leeches  behind  the  ears.  The 
simple  diluents  were  continued  ; two  blisters  were  applied  to  the  legs  on  the 
26th.  The  adynamic  state  attained  an  extreme  degree  on  the  30th  ; face  livid  ; 
eyes  extinct;  intellect  impaired;  pulse  very  frequent ; skin  not  hot ; tongue 
very  dry  ; stools  involuntary,  very  copious,  and  serous.  (Two  new  blisters  to 
the  thighs  ; mixture  consisting  of  five  ounces  of  infusion  of  orange  leaves,  a 
drachm  ( gros ) of  dry  extract  of  quinquina,  and  one  ounce  of  syrup  of  violet.) 

During  the  first  days  of  December,  the  strength  returned  a little  ; counte- 
nance improved.  (Same  treatment.)  The  patient  died  unexpectedly  on  the 
night  of  the  9th. 

Post-mortem.  Some  injection  of  the  gastric  mucous  membrane  in  its 
splenic  portion.  Nothing  remarkable  in  the  duodenum  and  the  upper  third  of 
the  small  intestine.  Large  clots  of  black  blood  filled  the  two  lower  thirds. 
Above  them  the  mucous  membrane,  to  the  extent  of  a foot  above  the  caecum, 
presented  merely  an  intense  colouring  owing  to  sanguineous  imbibition. 
Lower  down  there  existed  numerous  ulcerations  close  to  one  another.  Imme- 
diately below  the  caecal  valve  no  trace  of  blood  was  found.  The  caecum  was 
red,  and  presented  five  or  six  ulcerations.  The  remainder  of  the  large  intes- 
tine presented  but  a slight  redness,  arranged  in  numerous  patches. 

This  case  resembles  the  preceding,  both  in  the  form  of  its  commencement 
(diarrhcea  in  both  cases),  and  in  several  of  its  symptoms,  and  also  in  the  nature 
of  the  changes  found  in  the  intestine.  It  differed  from  it  in  the  uncommon 
circumstance  which  terminated  it,  at  a time  when,  during  the  exhibition  of 
tonics,  the  patient  seemed  to  be  improving.  No  particular  lesion  accounted 
for  this  profuse  and  sudden  hemorrhage ; it  was  not  even  announced  during 
life  by  any  bloody  stools. 

We  have  also  seen  a similar  hemorrhage  terminate  the  lives  of  three  other 
individuals,  who  were  likewise  attacked  with  typhoid  fever,  and  in  whose  in- 
testine was  found  the  exantheme  above  described,  either  simple,  or  with  ulcera- 
tion. In  these  three  cases  the  hemorrhage  had  been  announced  by  the  great 
quantity  of  blood,  which  the  patient  passed  by  the  anus  a few  hours  before 
death.  We  have  observed  another  instance  of  a similar  hemorrhage,  in  a me- 
dical student,  who  also  died,  but  on  whom  we  were  not  able  to  obtain  a post- 
mortem. He  was  affected  for  several  days  with  continued  fever,  which,  at 
first  apparently  mild,  was  subsequently  accompanied  with  profuse  epistaxis, 
and  an  alarming  state  of  stupor.  In  this  state  he  passed  for  the  first  time  a 


63 


ANDRAL’S  MEDICAL  CLINIC. 


stool  consisting  of  a great  quantity  of  black  very  fetid  blood,  as  pure  as  that 
which  would  have  been  obtained  from  a vein  with  the  lancet.  The  following 
days  he  had  several  similar  stools.  After  these  evacuations  he  fell  into  a state 
of  prostration,  which  went  on  increasing,  and  in  the  midst  of  which  he  died. 

Instead  of  being  exhaled  by  the  mucous  membrane  of  the  small  or  large  in- 
testine, as  in  the  subject  of  this  case,  the  blood  is  furnished  in  others  by  the 
gastric  mucous  membrane,  and  we  have  then  seen  individuals,  affected  with 
typhoid  fevers,  vomit  a black  matter,  like  coffee-grounds,  such  as  is  vomited 
either  in  yellow  fever,  or  in  certain  cancerous  affections  of  the  stomach. 

Case  24. — Pleuritis  at  the  commencement:  copious  bloodletting — Entrance  into  the  hospital 
in  a state  of  anaemia  ; tonic  treatment ; appearance  of  amendment ; then  a return  of  the 
serious  symptoms,  and  death — Ulcerations  at  the  extremity  of  the  small  intestine  ; injection 
of  the  gastric  mucous  membrane — Blood  liquid — Spleen  small  and  dense. 

A man,  about  twenty-seven  years  of  age,  was  brought  to  the  hospital  on  the 
1st  of  December,  in  the  last  stage  of  adynamic  prostration  : cadaveric  paleness 
of  the  face  and  lips  ; eyes  dull,  half  covered  by  the  eyelid;  pulse  very  frequent 
and  thready  ; skin  not  hot ; total  abolition  of  the  intellectual  faculties  ; tongue 
very  pale  and  dry.  We  ascertained  that  this  patient  had,  three  days  before,  a 
stitch  in  the  side;  that  within  the  last  forty-eight  hours  he  had  been  thrice  bled 
and  that  eighty  leeches  had  been  applied  to  him.  This  person  was  threatened 
with  sinking  very  soon  into  an  anemic  state  ; M.  Lerminier  thought  that  there 
was  an  urgent  necessity  to  raise  his  strength.  (Aqueous  infusion  of  quin- 
quina, aromatic  mixture,  with  the  addition  of  a drachm  of  ether;  camomile 
lavement,  with  the  addition  of  a scruple  of  camphor  ; two  blisters  to  the  legs  ; 
aromatic  frictions.) 

On  the  next  day  we  found  a very  perceptible  improvement;  countenance 
more  natural,  less  pale  ; some  of  his  answers  sufficiently  precise  to  questions 
addressed  to  him  ; pulse  raised  ; skin  moist,  and  of  a gentle  heat ; tongue  white 
and  moist;  abdomen  free  from  pain;  one  stool;  some  subsultus  tendinum. 
The  tonic  treatment  seemed  to  succeed  ; it  was  continued. 

On  the  3d  his  ideas  became  incoherent;  he  was  continually  complaining  ; 
yet,  in  the  midst  of  his  delirium,  his  answers  to  questions  were  sufficiently 
precise  ; face  always  very  pale,  as  also  the  tongue  ; constipation.  (Lavement 
of  quinquina  and  serpentaria,  of  each  an  ounce,  and  a scruple  of  camphor.) 

On  the  4th,  intellects  clearer  ; stammering  ; he  seems  no  longer  to  have  the 
power  of  directing  the  movements  of  his  tongue  ; pulse  always  frequent  and 
weak  ; skin  not  hot.  (The  same  prescription.) 

From  the  5th  to  the  9th,  the  patient  went  on  slowly  improving.  Strength  a 
little  increased  ; pulse  less  frequent ; skin  kept  up  a good  temperature  ; the 
tongue  recovered  a natural  appearance ; abdomen  soft  and  free  from  pain,  and 
the  stools,  though  passed  involuntarily,  were  few  in  number,  and  of  tolerable 
consistence.  The  patient  was  not  delirious,  properly  speaking,  but  his  intel- 
lects were  very  weak ; he  spoke  and  reasoned  like  a child.  The  infusion  of 
quinquina,  mineral  lemonade,  aromatic  ethereal  mixture,  frictions  to  the  limbs, 
lavement  of  kina,  serpentaria  and  camphor,  were  continued. 

On  the  10th,  the  progressive  amendment  of  the  preceding  days  was  gone. 
The  alteration  of  the  features  principally  announced  this  alarming  change. 
The  tongue  which,  on  the  day  before,  was  moist  and  of  a good  colour,  was 
dry  as  a bit  of  parchment.  Temperature  of  the  skin  was  raised.  (Same  pre- 
scription.) 

On  the  11th,  delirium  ; extreme  frequency  of  the  pulse  ; it  was  beyond  140. 
On  the  12th,  countenance  cadaverous  : extremities  cold  ; no  pulse  at  either 
arm  ; same  state  of  the  tongue  ; continual  cries  and  complaints  ; death  at  night. 


DISEASES  OF  THE  ABDOMEN. 


69 


Post-mortem , sixteen  hours  after  death.  Total  absence  of  subcutaneous  fat; 
muscles  gluey  and  livid. 

Brain  pale,  bloodless,  as  well  as  its  membranes.  Two  ounces  of  limpid 
serum  at  the  base  of  the  cranium. 

Albuminous,  membraniform  flocculi  scattered  over  the  pleurae  costalis  and 
pulmonalis  of  the  right  side,  without  the  effusion  of  any  liquid.  Red  hepati- 
sation  in  several  points  of  the  lower  lobe  of  the  left  lung. 

Heart  flaccid,  devoid  of  colour,  containing  a small  quantity  of  liquid  black 
blood  as  well  as  the  aorta. 

Inner  surface  of  the  stomach  red  in  the  splenic  portion.  This  redness  had  its 
seat  in  the  mucous  membrane  itself,  which  was  very  much  injected,  but  still 
retaining  its  ordinary  thickness  and  consistence.  Large  veins,  gorged  with  blood, 
traversed  the  laminated  tissue. 

Inner  surface  of  the  duodenum  and  the  remainder  of  the  small  intestine  slightly 
covered  with  bile  as  far  as  its  lower  fifth.-  In  this  latter  part  considerable  red- 
ness was  beginning  to  appear,  at  first  in  isolated  patches,  then  continued  to  the 
extent  of  a foot  and  a half  above  the  caecum.  These  three  small  superficial 
ulcerations  were  observed  to  exist,  each  sufficient  to  hold  a centime  at  most,  the 
bottom  of  which  presented  a greyish  colour,  which  was  not  removed  by  washing. 
The  caecum  was  also  very  much  injected,  the  remainder  of  the  large  intestine 
was  white,  and  filled  with  hard  matter.  The  spleen  was  remarkably  small  and 
dense. 

The  ulcerations  of  the  ileum  were  here  very  inconsiderable;  around  them  no 
follicle  was  found  developed ; but  there  was  in  different  points  of  the  gastro- 
internal  mucous  membrane  a brighter  redness  than  in  other  subjects.  The  mem- 
braniform flocculi  found  in  the  pleura  proved  the  existence  of  pleuritis,  which 
seemed  to  have  been  the  primary  disease  with  this  individual.  The  copious 
bleedings  resorted  to  one  after  another  to  combat  this  pleuritis,  before  the  patient 
entered  the  hospital,  might  have  contributed  to  throw  him  into  the  very  marked 
adynamic  state  which  he  presented  the  first  time  we  saw  him  ; a tonic  treatment 
was  tried  ; it  seemed  at  first  to  succeed  ; it  was  continued,  and  whilst  the  patient 
was  taking  quinquina,  serpentaria,  camphor,  and  ether,  the  pulse  fell,  the  tongue 
returned  to  its  natural  state,  the  countenance  assumed  a better  appearance,  the 
abdomen  continued  soft  and  free  from  pain;  only  there  was  always  great  debility. 
The  intellect  was  that  of  a child,  and  the  stools  passed  involuntarily.  All  at 
once  this  progressive  amendment  ceases,  the  tongue  again  becomes  dry,  delirium 
supervenes  ; pulse  becomes  very  frequent,  and,  in  consequence  of  this  kind  of 
recrudescence,  the  patient  dies.  What  was  the  cause  of  it?v  The  ulcerations  of 
the  ileum  existed  probably  before  the  10th  of  December;  probably  also  they  were 
already  formed  at  the  time  the  patient  entered  the  hospital,  and  it  may  be  admitted 
that  at  the  time  his  state  improved,  the  intestinal  ulcerations  diminished  in  extent ; 
they  were  then  probably  in  progress  of  cure  when  we  examined  them.  It  may 
be  asked  whether  the  gastro-intestinal  mucous  membrane,  irritated  by  the  long 
continued  contact  of  stimulants,  became  suddenly  the  seat  of  hyperemia  on  the 
10th  of  December?  Is  it  only  from  this  day  we  are  to  date  the  development  of 
the  redness  which  was  found  in  several  points  of  the  stomach  and  intestines? 
Did  this  congestion,  having  supervened  in  an  individual  already  much  debilitated, 
occasion  the  appearance  of  the  serious  ataxo-adynamie  symptoms  of  the  last  few 
days  ? 

We  may  again  notice,  1st,  the  bloodless  state  of  the  brain  and  its  mem- 
branes, coinciding  with  a certain  quantity  of  serum  accumulated  at  the  base  of 
the  brain. 

2dly.  The  liquid  state  of  the  blood. 

3dly.  The  small  size  and  density  of  the  spleen,  which,  in  most  of  the  other 
cases,  we  found  so  large  and  so  soft. 


70 


ANDRAL’S  MEDICAL  CLINIC. 


Case  25. — Recent  arrival  at  Paris — Slight  continued  fever ; subsequently  adynamic  symptoms ; 
disappearance  of  the  latter;  continuance  of  a slight  purging;  then  cerebral  symptoms,  and 
death  on  the  thirty-sixth  day — Tonic  treatment  continued  for  a long  time — Follicular  patches 
of  the  small  intestine  more  apparent  than  usual ; follicles  of  the  large  intestine  also  more 
apparent. 

A man,  twenty-two  years  of  age,  residing  in  Paris  for  seven  months,  with  fair 
skin,  brown  hair,  small  muscles,  in  the  habitual  enjoyment  of  good  health,  felt, 
on  the  8th  of  May,  without  any  known  cause,  great  lassitude,  wandering  pains 
through  the  limbs,  and  violent  sub-orbital  headach.  These  symptoms  continued 
on  the  following  days.  He  kept  quiet,  and  observed  strict  diet.  He  entered 
the  hospital  on  the  evening  of  the  13th. 

On  the  14th,  face  flushed  ; eyes  sunk ; his  features  altogether  presented  an  air 
of  remarkable  stupor.  Movements  painful ; indifference  in  answering  questions  ; 
pulse  scarcely  frequent,  full  enough,  but  irregular;  skin  hot  and  moist;  tongue 
red  ; thirst;  continuance  of  the  constipation.  (Barley  ptisan,  linseed  lavement, 
diet.) 

Same  state  on  the  15th  and  16th.  A stool  each  day.  Every  three  ^pulsations 
the  pulse  had  a well  marked  stop. 

On  the  17th,  stupor,  and  air  of  prostration  were  remarkably  increased.  At  the 
same  time  there  was  redness  and  dryness  of  the  tongue  ; two  liquid  stools ; in- 
creased frequency  of  the  pulse,  which  lost  its  irregularity ; burning  heat  of  the 
skin.  Inflammation  of  the  digestive  mucous  membrane  more  marked  than  on 
the  preceding  days.  The  great  stupor  in  which  the  patient  lay,  contra-indi- 
cated the  employment  of  bloodletting,  or  was  this  stupor  but  the  effect  of  the 
intestinal  inflammation?  M.  Lerminier,  after  raising  these  questions,  tried  the 
application  of  thirty  leeches  to  the  anus.  Their  bites  flowed  profusely.  Pro- 
fuse sweat  came  on  during  the  night.  On  the  day  after,  the  1 8th,  there  was 
undoubtedly  an  improvement ; particularly  the  appearance  of  the  face  was  more 
natural  ; the  features  not  so  sunk  ; the  tongue  was  now  moist,  and  the  fever 
was  diminished. 

On  the  19th  the  serious  symptoms  of  the  17th  reappeared.  The  happy  effect 
of  the  former  application  of  leeches  inclined  M.  Lerminier  to  try  a second  ; but 
this  time  it  did  not  appear  to  have  so  favourable  a result.  To  be  sure,  on  the 
next  day,  we  found  the  fever  moderated,  the  tongue  moist  and  of  a good  colour ; 
but  the  prostration  had  increased  ; the  speech  was  a little  embarrassed  ; the 
tendency  to  the  adynamic  state  was  evident. 

On  the  other  hand  the  symptoms  of  intestinal  irritation  seemed  but  very  slight ; 
there  was  but  little  frequency  of  pulse.  Two  blisters  were  applied  to  the  legs  ; 
two  cups  of  aqueous  infusion  of  quinquina  were  given. 

The  two  following  days  the  tongue  became  red  and  dry.  Only  one  liquid  stool 
occurred  every  twenty-four  hours.  The  abdomen  still  retained  some  softness. 
The  quinquina  was  succeeded  by  a decoction  of  polygala  with  gum. 

On  the  22d  and  24th,  tongue  was  moist,  and  lost  its  red  colour.  On  the  eve- 
ning of  the  24th,  profuse  sweat;  on  the  25th,  sweating  on  the  abdomen;  ex- 
pectoration, since  the  preceding  day,  of  a considerable  quantity  of  yellowish, 
very  thick  sputa.  Remarkable  amendment. 

On  the  four  days  after,  very  profuse  sweats,  copious,  purulent  sputa.  Slight 
purging  set  in.  The  amendment  became  more  and  more  marked.  (Same  medi- 
cines, some  broths.) 

On  the  30th,  he  complained  of  having  felt  the  entire  night  severe  pains  in  the 
limbs.  At  the  visit  we  found  him  perspiring,  as  on  the  preceding  days,  but  we 
observed  that  the  fingers  of  the  two  hands,  except  the  index  fingers,  were  flexed 
forcibly  on  the  palm.  The  patient  could  extend  them  but  very  imperfectly,  and 
with  considerable  difficulty.  He  was  going  on  in  other  respects  very  well,  had 


DISEASES  OF  THE  ABDOMEN.  71 

no  fever,  and  might  be  considered  convalescent.  (Infusion  of  camomile,  rice 
cream,  broths,  a little  wine.) 

From  the  13th  of  May  to  the  3d  of  June,  three  ounces  of  syrup  of  quinquina 
were  given  every  day,  principally  with  the  view  of  combating  the  profuse  sweats 
which,  being  prolonged  beyond  measure,  seemed  to  retard  the  progress  of  con- 
valescence. 

On  the  3d  of  June  the  quinquina  was  substituted  for  the  syrup.  M.  Chomel, 
who  took  up  the  temporary  management  of  the  ward,  tried  to  stop  the  slight 
purging,  which  continued,  by  adding  to  the  barley  ptisan  a small  quantity  of 
muriatic  acid. 

From  the  3d  to  the  9th,  the  state  of  the  patient  remained  nearly  the  same. 
He  became  cast  down,  and  his  strength  was  not  re-established.  The  flexion  of 
the  fingers  continued. 

On  the  10th  the  stupor  reappeared  ; pulse  again  became  frequent.  The 
patient  had  been  told  that  the  plague  reigned  in  the  Parisian  hospitals.  This 
false  news  alarmed  him  very  much,  and  he  considered  himself  as  doomed  to 
inevitabl^Heath. 

On  the  11th  and  12th  features  rapidly  decomposed;  slight  convulsive  move- 
ments of  the  levator  muscles  of  the  left  commissure  of  the  lips;  eyes  fixed  and 
wide  open;  pupils  equally  dilated;  flexion  of  the  fingers;  intellect  clear; 
pupils  slow  ; tongue  moist  and  bright  red  ; from  two  to  three  stools.  (Same 
prescription.) 

On  the  morning  of  the  13th  the  countenance  had  a cadaveric  aspect.  The 
extremities  were  icy  cold.  A cold  sweat  oozed  from  the  entire  surface  of  the 
skin.  The  pulse  was  no  longer  felt.  Still  the  intellect  retained  all  its  clear- 
ness. The  patient  continually  asked  to  drink.  The  tongue  retained  its  natu- 
ral appearance.  Considerable  epistaxis  had  occurred  the  evening  before.  He 
died  in  the  course  of  the  day. 

Post-mortem.  About  a spoonful  of  limpid  serum  was  found  in  each  lateral 
ventricle.  None  was  found  at  the  base  of  the  cranium.  Lungs  very  slightly 
engorged  posteriorly. 

Abdomen.  — The  stomach  when  viewed  exteriorly  was  divided  into  two  por- 
tions by  a circular  contraction  at  nearly  its  middle  part.  The  small  intestine, 
including  the  duodenum,  was  very  pale,  as  far  as  about  half  a foot  above  the 
caecum.  It  merely  presented,  in  its  lower  part,  six  or  seven  oval  patches,  the 
bottom  of  which,  being  greyish,  was  studded  with  a number  of  small  black 
points,  close  one  to  the  other.  At  about  six  inches  above  the  caecum,  the  mucous 
membrane  was  considerably  injected,  but  had  not,  however,  lost  its  transparence. 
The  inner  surface  of  the  large  intestine,  from  the  caecum  to  the  rectum,  was 
studded  with  a great  quantity  of  small  black  points  isolated,  and  notagglomerated, 
as  in  the  small  intestine.  Around  them  the  mucous  membrane  made  a slight 
projection,  the  result  of  which  was  an  appearance  entirely  similar  to  that  pre- 
sented by  the  mucous  cryptae  of  the  skin  when  they  have  attained  greater 
development  than  ordinary.  Between  them  the  mucous  membrane  was  white 
in  several  points,  and  injected  in  other  points. 

Do  we  find  in  this  patient  any  lesion  sufficient  to  account  for  the  symptoms 
and  death  l 

In  order  to  answer  this  question,  it  is  necessary  to  distinguish  in  this  disease 
the  three  following  stages  : — 

Is*  stage.  It  commences  at  the  time  of  the  invasion  and  extends  to  the  period 
at  which  the  patient  entered  the  hospital. 

2 d stage.  Commencing  at  this  last  period ; it  is  characterised  by  the  ap- 
pearance of  the  purging,  the  dryness  of  the  tongue,  and  the  progress  of  the 
stupor. 

3 d stage.  It  commences  on  the  31st  of  May  ; the  signs  of  a cerebral  affection 


72 


ANDRAL’S  MEDICAL  CLINIC. 


predominate ; the  tongue  resumed  its  natural  appearance,  a little  purging 
continues. 

During  the  two  first  stages  the  intestinal  follicles  were  very  probably  the  seat 
of  an  inflammation,  the  intensity  of  which  increased  with  the  severity  of  the 
symptom  ; if  the  patient  had  died  at  this  stage,  very  probably  Peyer’s  patches 
would  have  been  found  red,  swollen,  and  forming  on  the  inner  surface  of  the 
small  intestine  those  oval  elevations  of  which  we  have  had  numerous  instances 
in  the  preceding  cases ; at  a little  later  period  we  might  have  found  with  this 
exantheme  of  the  small  intestine  numerous  red  pustules  ( boutons ) scattered  over 
the  large  intestine  ; we  then  might  have  been  able  readily  to  establish  a 
relation  between  the  symptoms  observed  during  life,  and  the  intestinal  lesions 
found  after  death,  and  this  case  would  have  afforded  merely  a repetition  of  the 
preceding.  But  it  was  not  in  these  first  two  stages  that  the  patient  died  ; far 
from  it,  the  alarming  symptoms  which  he  then  presented,  improved  ; the  purg- 
ing diminished  ; the  tongue  became  moist ; the  strength  was  raised  ; and  what 
is  called  the  adynamic  state  disappeared  ; the  intestinal  lesions  which  we  have 
seen  hitherto  uniformly  correspond  with  this  state,  must  then  alsdftliminish  ; 
this  is  accordingly  what  took  place  ; and  when  we  opened  the  body,  we  found 
no  trace  of  it  but  an  unusual  development  of  the  follicles  of  the  ileum  and  of 
the  large  intestine  ; again,  in  a little  time  these  follicles  would  have  been  com- 
pletely effaced,  or  else  they  would  have  continued,  and  the  individual  would 
have  remained  subject  to  frequent  returns  of  diarrhoea,  without  other  serious 
symptoms.* 

The  disease  then  was  progressing  towards  a cure  when  new  symptoms  super- 
vened, which  seemed  to  have  their  origin  in  a serious  lesion  of  the  nervous 
centres  ; no  appreciable  lesion  of  these  centres  was  found  in  order  to  explain 
them  ; however,  the  stupor,  which  in  twenty-four  hours  became  extreme,  the 
peculiar  expression  of  the  eyes,  the  permanent  contraction  of  the  flexors  of  the 
fingers,  the  convulsive  movements  of  the  muscles  of  the  face,  finally,  even  the 
nature  of  the  cause  to  which  the  relapse  might  be  attributed,  seemed  to  indicate 
the  existence  of  acute  meningitis.  There  was  observed,  however,  neither  pain 
of  head,  nor  delirium.  But  in  how  many  varieties  of  meningitis  do  we  not  see 
these  symptoms  wanting? 

In  this  3d  stage  was  another;, organ  the  seat  of  a lesion  which  might  account 
for  the  nervous  symptoms  which  characterise  it?  Had  the  brain,  which  was 
found  healthy,  been  but  sympathetically  irritated  ? In  vain  we  sought  for  this 
seat  in  the  remainder  of  the  digestive  tube,  which  presented  nothing  abnormal 
except  this  development  of  the  follicles,  to  which  we  have  already  directed 
attention.  Such  as  we  found  it  at  the  time  we  examined  the  body,  it  was  very 
evident  that  this  lesion  of  the  follicles  could  exercise  no  influence  on  the  symp- 
toms of  the  third  stage.  Here  then  is  a well-marked  case  in  which  pathologi- 
cal anatomy  cannot  account  in  any  way  either  for  the  functional  disturbances, 
or  for  the  death  of  the  patient. 

But  the  disease,  though  not  having  left  in  the  organs  any  trace  of  its  exist- 
ence, had  nevertheless  a most  evident  seat ; the  symptoms  indicated  that  this 
seat  resided  in  the  nervous  system.  The  brain,  strongly  acted  on  by  an  intense 
moral  emotion,  was  irritated,  and  drew  to  itself  the  little  strength  which  the 

* We  have  found  a similar  development  of  the  intestinal  follicles,  1st,  in  persons,  who, 
several  months  before,  had  had  what  is  called  adynamic  fever;  2dly,  in  others,  who  never  had 
any  such  disease,  but  in  whom  for  a longer  or  shorter  time,  there  existed  a chronic  diarrhoea ; 
3dly,  in  some  other  individuals,  who,  never  having  had  a bad  fever,  had  not  even  been  affected, 
with  purging  towards  the  termination  of  life.  It  is  very  common  to  find  them  in  the  intes- 
tines of  animals,  in  those  of  dogs,  horses,  and  sheep.  It  appears  that  the  intestinal  follicular 
apparatus  is  naturally  more  developed  in  these  animals  than  in  man ; likewise  what  in  them 
as  an  entirely  physiological  state,  can  no  longer  be  regarded  as  such  in  man. 


DISEASES  OF  THE  ABDOMEN. 


73 


individual  still  possessed.  Thence  the  increase  of  the  prostration,  which  made 
rapid  progress,  at  the  same  time  that  the  nervous  centres  appeared  to  become 
the  seat  of  a constantly  increasing  vital  action.'?' 

Let  us  now  direct  our  attention  to  some  of  the  phenomena  of  the  disease  and 
to  its  treatment. 

The  tongue,  red  and  white  in  the  first  stage,  dry  in  the  second,  presented  in  the 
third  a natural  appearance.  However,  with  this  natural  state  of  the  tongue,  and 
though  on  opening  the  body  the  stomach  was  found  to  be  very  healthy,  the 
patient  was  tormented  with  a burning  thirst.  This  thirst  seemed  to  be  sympa- 
thetic of  the  state  of  the  brain,  in  the  same  manner,  as  under  other  circumstances, 
we  see  delirium,  convulsions,  etc.,  manifest  themselves,  as  phenomena  sympa- 
thetic of  the  state  of  the  stomach.  Most  of  the  acts  of  the  life  of  nutrition  may 
thus  be  increased,  diminished,  or  perverted  in  their  exercise  by  the  sole  influ- 
ence of  the  nervous  system,  and  without  corresponding  material  lesion. 

The  constipation  existed  at  the  commencement  of  the  disease  at  a period  when 
very  protably  disease  of  the  follicles  already  existed  ; it  was  replaced  towards 
the  thirteenth  day  by  a purging  which  was  never  very  considerable,  but  which 
continued  up  to  the  last. 

The  abdomen  was  considerably  soft  and  free  from  pain. 

The  pulse  presented  remarkable  irregularity  at  a time  when  the  disease  as 
yet  presented  nothing  serious.  This  irregularity  disappeared  according  as  the 
disease  assumed  a more  unfavourable  character.  Can  we  assimilate  this  case  to 
that  of  a man  mentioned  by  De  Haen,  whose  pulse,  intermittent  in  the  state  of 
health,  became  irregular  every  time  he  had  fever  ? Shall  we  again  assimilate  it 
to  the  following  case  cited  by  Rasori  ? (Petechial  fever  of  Genoa,  Case  14.)  In 
an  individual  attacked  with  the  epidemic  disease,  the  pulse,  which  during  its 
progress  had  never  been  intermitting,  became  so  on  the  cessation  of  the  fever  ; 
the  patient  then  stated,  that  in  his  habitual  slate  of  health  he  had  an  intermitting 
pulse. 

The  treatment  was  at  first  antiphlogistic  ; and  we  have  seen  how  useful  the 
first  application  of  leeches  was.  Under  its  influence,  not  only  did  the  symptoms 
of  the  gastro-intestinal  inflammation  improve,  but  also  the  stupor  disappeared, 
and  the  strength  rose.  After  this  first  bloodletting  a profuse  sweat  came  on ; 
but  the  improvement  was  but  temporary,  and  the  second  application  of  leeches 
was  far  from  being  as  serviceable  as  the  first ; at  least  it  was  followed  by  a rapid 
increase  of  the  prostration.  Did  this  different  result  of  the  two  bleedings  prove 
that,  when  the  first  was  resorted  to,  the  strength  was  only  oppressed,  whilst  at 
a later  period  a real  adynamic  state  existed  ? Brown  would  have  seen  here  a 
case  of  that  indirect  debility,  which  he  considered,  as  succeeding,  in  most  dis- 
eases, the  sthenic  stage.  Tonics  were  then  tried  ; but  the  quinquina  was 
scarcely  given  when  the  tongue  became  dry  ; it  was  followed  by  poly  gala  root ; 
and  during  the  use  of  the  latter  substance  the  tongue  became  moist. 

However,  the  disease  did  not  attain  a crises  ; its  prognosis  was  still  very  un- 
certain, when  on  the  evening  of  the  sixteenth  day,  profuse  sweats  and  puriform 
expectoration  spontaneously  set  in.  This  double  evacuation  which  was  accom- 
panied by  a well-marked  improvement,  continued  to  go  on  the  four  or  five  fol- 
lowing days.  Was  it  critical,  in  the  sense  which  authors  attach  to  this  term  ? 
We  have  seen  in  the  other  parts  of  this  work,  and  we  shall  again  see  in  the 
present  part,  a certain  number  of  cases  in  which  there  was  a remarkable  coin- 
cidence between  the  appearance  of  a sweat  and  the  rapid  transition  from  a bad 
state  to  a decided  convalescence ; but  it  is  more  rare  to  see  the  appearance  of 
sputa  coincide  with  such  a change.  On  reading  the  works  of  authors  it  is  easy 
to  see  that  the  sputa  which  they  have  called  critical,  are  frequently  nothing  else 
than  the  natural  termination  of  a pulmonary  catarrh  which  complicated  the  dis- 
ease, and  which  was  resolved  simultaneously  with  it.  It  does  not  appear,  how- 


74 


AN  DUAL’S  MEDICAL  CLINIC. 


ever,  that  such  was  the  case  with  our  patient.  He  expectorated  all  at  once 
opaque,  purulent  sputa,  without  having  presented  on  the  preceding  days  any 
symptoms  of  pulmonary  irritation  ; but  he  had  not  been  examined  with  the 
stethoscope. 

We  should  observe  also  that  the  sweat  lasted  beyond  the  time  during  which 
it  could  be  considered  as  critical. 

Case  26. — Recent  arrival  at  Paris — Symptoms  of  typhous  fever — Treatment  by  bloodletting 

at  the  commencement ; at  a later  period  simple  diluent  drinks — Death  by  pneumonia  during 

convalescence — White  ulcerations  towards  the  extremity  of  the  small  intestine. 

A mason,  twenty-eight  years  of  age,  residing  in  Paris  for  only  a few  months, 
entered  the  Charite  with  the  different  symptoms  which  characterise  bilious 
fever;  sub-orbital  headach  ; yellow  tint  around  the  lips  and  alae  nasi;  great 
flush  on  the  cheeks;  tongue  covered  with  a thick  yellowish  coat;  bitter  taste 
in  the  mouth  ; desire  for  acid  drinks  ; thirst;  abdomen  soft  and  free  from  pain  ; 
three  or  four  liquid  stools  in  the  twenty-four  hours  ; pulse  frequent  «nd  hard  ; 
acrid  heat  of  skin  ; answers  embarrassed  and  painful ; intellect  dull,  the  patient 
lias  but  a confused  recollection  of  what  happened  him  previous  to  his  entering 
the  Charite.  (Twenty leeches  to  the  anus  ; barley  ptisan;  diet.) 

Same  state  next  day  (barley  ptisan  ; sinapisms). 

On  the  following  days  the  tongue  became  red  and  dry  ; abdomen  slightly 
tympanitic  ; purging  continues  ; intellect  more  and  more  obtuse  ; same  delirium 
from  time  to  time.  A bleeding  of  twelve  ounces  was  resorted  to  ; twenty-four 
hours  after  every  thing  became  worse  ; the  patient  no  longer  answers  questions  ; 
the  tongue  was  observed  to  be  dry  and  cleft ; a viscid  mucus,  of  a dirty  grey  co- 
lour, covered  the  lips  and  teetli  ; seven  or  eight  liquid  stools  ; pulse  very  fre- 
quent and  weak  ; skin  had  but  little  heat;  some  subsultus  tendinum.  (Barley 
ptisan  with  gum;  diet;  sinapisms  to  the  legs.) 

During  the  six  following  days  the  state  of  the  patient  remained  unchanged  ; 
nothing  given  him  but  the  barley  ptisan. 

At  the  end  of  this  time  the  intellects  gradually  recovered  their  integrity,  the 
stupor  diminished ; the  movements  became  more  free  ; the  tongue  became  moist ; 
the  lips  and  teeth  became  clean  ; the  purging  diminished  ; but  did  not  entirely 
disappear. 

The  patient  was  soon  considered  convalescent;  he  no  longer  presented  any 
other  morbid  phenomena  but  a little  purging;  the  skin  remained  constantly 
dry.  Some  broths  were  allowed  him,  then  some  potage,  and  also  a little 
wine. 

The  state  of  convalescence  became  more  and  more  established,  though  there 
still  remained  a little  purging,  when  one  day  we  ascertained  the  return  of  the 
fever  ; the  patient  told  us  that  since  the  day  before  he  was  attacked  with  a 
stitch  in  the  side  ; we  soon  discovered  all  the  signs  of  commencing  pneumonia. 
On  the  following  days  it  became  more  and  more  intense,  and  terminated  in 
death.  No  bleeding  employed  ; blisters  were  applied  to  the  chest  and  lower 
extremities. 

Post-mortem.  Red  hepatisation  of  the  lower  and  middle  lobe  of  the  right  lung; 
slight  membraniform  exudation  on  the  pleura  of  this  side. 

Remarkable  paleness  of  the  gastro-intestinal  mucous  membrane,  from  the  car- 
diac orifice  to  the  anus.  At  the  distance  of  a foot  below  the  caecum  we  found 
live  or  six  white  points  where  the  mucous  membrane  was  wanting.  In  its  stead 
the  submucous  cellular  tissue  was  found  exposed,  which  was  not  in  any  way 
changed. 

It  appears  to  us  probable  that  the  parts  of  the  ileum  where  we  found  no  mucous 
membrane  were  the  seat  of  old  ulcerations  which  were  on  the  point  of  cica- 
trising ; a slight  diarrhoea  was  the  only  sign  which  could  incline  us  to  think  that 


DISEASES  OF  THE  ABDOMEN. 


75 


there  was  still  some  lesion  of  the  digestive  passages  when  every  thing  announced 
a state  of  convalescence.  If  the  pneumonia  had  attacked  this  individual  only  a 
little  later,  it  is  very  probable  that  we  could  not  have  found  ulcerations,  properly 
speaking,  and  that  in  those  places  where  we  found  the  submucous  cellular  tissue 
exposed,  we  would  have  met  a membrane  of  new  formation,  similar  to  that  of 
which  the  following  case  will  present  us  an  example. 

If  it  cannot  be  affirmed  that  in  the  subject  of  this  case  the  bloodletting  was 
iujurious,  at  least  it  may  be  remarked  that  it  did  not  arrest  the  progress  of  the 
disease  ; far  from  it,  the  day  after  the  bleeding,  the  adynamic  state  was  more 
decided,  and  all  the  symptoms  became  evidently  aggravated.  We  think  that 
much  harm  would  have  been  done  by  following  up  the  bleeding.  On  the  other 
hand,  would  tonics  have  been  useful  ? The  preceding  case  would  incline  us  to 
answer  the  question  in  the  affirmative.  Be  that  as  it  may,  we  refrained  from 
them  here  entirely,  and  if  we  except  some  sinapisms  applied  to  the  legs,  the  patient 
was  entirely  left  to  nature.  Alone,  she  sufficed  to  bring  this  serious  affection  to  a 
happy  termination;  alone  also,  she  would  probably  have  finished  the  entire  cica- 
trisation of  the  intestinal  ulcers. 

This  cicatrization  is  sometimes  deferred  for  a very  long  time  ; there  are  cases 
where  the  ulcers  survive  the  acute  disease,  and  occasion  chronic  diarrhoea,  which 
is  accompanied  by  a slow  fever,  and  ultimately  carries  the  patients  to  the  grave 
after  having  gradually  reduced  them  to  the  last  degree  of  marasmus.  We  saw 
an  instance  of  this  in  a young  girl,  seventeen  years  of  age,  who  entered  the 
Maison  de  Sante  with  the  very  worst  symptoms  of  an  ataxo-adynamic  fever. 
For  nearly  a month  she  had  the  tongue  dry  and  black,  the  abdomen  tympanitic, 
continual  diarrhoea,  a very  frequent  pulse,  an  acrid  heat  of  skin,  and  different 
nervous  symptoms,  such  as  stupor,  delirium,  coma,  subsultus  tendinum,  etc. 
At  the  end  of  this  time  the  tongue  again  became  moist  and  pale,  the  abdomen 
fell,  the  nervous  symptoms  disappeared,  the  skin  lost  its  heat,  but  the  pulse  re- 
tained a little  frequency,  and  the  diarrhoea  did  not  stop.  The  purging  con- 
tinued for  the  two  following  months  ; five  or  six  stools  occurred  every  day,  the 
abdomen  in  other  respects  was  flat  and  completely  free  from  pain.  There  was 
no  other  morbid  phenomenon  but  this  diarrhoea,  and  the  patient  continued  to 
pine  away  from  day  to  day,  and  fell  into  a state  of  marasmus.  She  died  in 
three  months.  Some  leeches  applied  at  the  commencement,  either  to  the  anus, 
or  over  the  abdominal  parietes,  blisters  applied  to  different  points  of  these  same 
parietes,  lavements  with  the  laudanum  or  diascordium  frequently  repeated  ; at 
a later  period  lavements  with  the  addition  of  rhatany  root ; simple  mucilaginous 
drinks  given  by  the  mouth  ; such  were  the  principal  means  employed  ; they 
were  ineffectual.  A strict  diet  was  at  first  observed  ; subsequently  the  patient 
was  nourished  with  different  feculas,  milk  and  eggs.  She  took  her  food  with 
pleasure,  except  during  the  last  fifteen  days  of  her  life,  when  bilious  vomitings 
set  in  which  accelerated  death  some  days.  At  the  post-mortem  we  found  the 
following  morbid  appearances  in  the  digestive  tube. 

All  the  inner  surface  of  the  small  intestine  was  remarkably  pale,  and  all  its  , 
coats  were  very  much  attenuated.  In  the  lower  sixth  of  the  ileum,  we  found  a 
number  of  Peyer’s  patches  which  formed  a slight  projection  above  the  level  of 
the  mucous  membrane,  and  which  presented  a bluish  tint.  Close  to  the  caecum 
there  existed  four  ulcerations,  two  of  which  might  each  have  admitted  a five 
franc  piece,  and  the  other  two  did  not  exceed  in  diameter  a forty-sous  piece. 
The  bottom  of  these  four  ulcers  was  formed  by  the  muscular  tunic,  and  here 
and  there  we  observed  in  this  same  bottom,  which  was  white,  some  debris  of  the 
mucous  membrane  which  had  a bluish  black  tint.  This  same  tint  appeared, 
for  the  space  of  two  lines,  around  each  ulcer. 

The  inner  surface  of  the  large  intestine  presented  a great  number  of  small 


76 


ANDRAL’S  MEDICAL  CLINIC. 


black  points,  which  appeared  to  us  to  be  so  many  follicles  : between  these 
points  the  mucous  membrane  was  white,  but  very  friable. 

The  mesenteric  ganglions  were  but  slightly  developed. 

With  respect  to  the  stomach  it  was  coloured  with  bile  on  its  inner  surface 
through  nearly  all  its  extent.  Its  mucous  membrane  was  every  where  of  good 
consistence ; it  presented  towards  the  pyloric  region,  somewhat  of  a mamil- 
lated  appearance,  not  the  least  trace  of  injection  was  found  in  it.  Thus  the 
bilious  vomiting  which  took  place  towards  the  termination  of  life  could  not  be 
explained  by  an  inflammatory  state  of  the  stomach,  and  the  cause  which  for 
several  successive  days  had  brought  bile  into  this  organ,  entirely  escaped  us. 
The  liver  was  merely  pale. 

We  should  add  that,  as  in  the  cases  where  death  supervened  during  the  acute 
stage,  we  found  the  spleen  doubled  in  size,  and  softened. 

In  the  cases  now  given,  the  continuance  of  the  ulcerations  kept  up  the  diar- 
rhoea, a long  time  after  all  the  symptoms  of  the  acute  stage  had  disappeared. 
Here  is  another  case  which,  like  the  preceding,  occurred  at  the  Maison  de 
Sante,  in  which,  though  the  ulcerations  also  continued,  the  diarrhoea  ceased,  at 
the  same  time  that  all  the  symptoms  improved.  The  subject  of  this  case  was 
a man  twenty-two  years  of  age,  who  was  admitted  into  our  wards  with  the 
different  symptoms  of  typhoid  fever  (stupor,  disturbance  of  the  intellect, 
great  prostration,  tongue  dry  and  dark,  gaseous  development  of  the  abdomen, 
profuse  diarrhoea,  pulse  very  frequent,  rose-coloured  spots  over  the  abdomen). 
By  degrees  these  symptoms  improved,  and  a sort  of  convalescence  seemed  to 
commence;  the  tongue  took  on  the  most  natural  appearance;  the  abdomen  had 
become  soft;  when  pressed  on  every  point,  it  was  free  from  pain ; the  purging 
had  ceased , and  it  became  necessary  to  administer  lavements,  in  order  to  pro- 
duce alvine  evacuations.  But  on  the  other  hand,  the  frequency  of  the  pulse 
did  not  cease  ; the  patient  continued  to  waste  away,  and  every  day  his  strength 
diminished.  He  remained  for  three  months  in  this  state,  complaining  of  no 
pain,  having  his  intellects  perfect,  taking  some  mild  aliment,  and  seeming  to 
digest  them  ; never  going  to  stool,  unless  after  the  administration  of  a lavement, 
and  never  passing  any  thing  but  some  hard  scybala.  Having  arrived  by  degrees 
at  an  extreme  degree  of  marasmus,  he  ceased  to  speak,  his  extremities  became 
cold,  his  pulse  disappeared,  and  he  expired,  after  having  merely  lost,  during 
the  last  twenty-four  hours  of  his  life,  a little  of  the  clearness  of  his  intellect. 
The  purging  did  not  reappear  for  a single  instant ; the  urine  was  remarkable 
for  the  insupportable  feetor,  which  exhaled  from  it  at  the  moment  it  was  being 
voided,  it  was  at  the  same  time  very  turbid. 

The  post-mortem  presented  the  following  changes  : 

No  appreciable  alteration  existed  in  the  encephalon  and  its  appendages.  The 
left  lung,  remarkable  for  its  great  lightness,  contained  no  blood  ; the  right  lung 
was  heavier  ; towards  the  lower  part  of  its  upper  lobe,  there  existed  a circum- 
scribed engorgement,  which  occupied  the  size  of  a large  nut;  in  this  part  the 
* pulmonary  parenchyma  was  impervious  to  air,  granulated  on  being  cut  into,  of 
a dirty  grey  colour,  and  very  friable.  The  posterior  part  of  this  same  lung  was 
engorged. 

The  tissue  of  the  heart  was  firm  and  pale.  Its  cavities  contained  clots  formed 
of  white  fibrin.  The  vessels  were  not  coloured,  and  contained  a little  liquid 
blood.  At  the  union  of  its  upper  four-fifths  with  its  lower  fifth,  the  oesophagus 
presented  two  oval  ulcerations,  the  greater  diameter  of  which  lay  in»the  direc- 
tion of  the  axis  of  the  oesophagus.  A little  below  these  ulcerations,  the  epithe- 
lium was  destroyed,  then  it  reappeared  under  the  form  of  an  irregularly  cut 
band,  to  the  extent  of  an  inch  in  breadth  around  the  cardia. 

The  stomach  was  every  where  white  on  its  inner  surface.  In  the  pyloric 


DISEASES  OF  THE  ABDOMEN. 


77 


portion  the  mucous  membrane  was  mamillated  ; in  the  splenic  part  it  was 
sufficiently  thin;  it  existed  however  every  where  in  this  part,  and  everywhere 
it  could  be  detached  in  shreds  from  the  subjacent  tissues.  The  stomach  con- 
tained a small  quantity  of  liquid  free  from  any  odour. 

The  duodenum  presented  nothing  but  a yellow  colouring  of  the  free  edge  of 
the  valves. 

The  ileum,  in  its  lower  fourth,  presented  a great  number  of  Brunner’s  folli- 
cles, white,  and  forming  a projection  above  the  level  of  the  mucous  membrane, 
and  still  further  half  a dozen  elliptical  patches.  These  had  a black  colour, 
which  constituted  as  it  were  their  bottom.  Above  this  black  bottom,  there  was 
observed  a certain  number  of  agglomerated  follicles,  similar  to  those  of  Brunner, 
and  forming  by  their  assemblage  as  it  were  a second  plane  not  continued,  and 
of  a greyish,  white  colour,  above  the  other  plane,  which  was  deeper  and  blacker. 
In  certain  points  of  these  patches,  ulcerations  were  found,  whose  edges  were 
black,  and  whose  bottom,  on  a level  with  the  edges,  was  formed  of  the  mus- 
cular membrane,  the  transverse  fibres  of  which  were  seen  exposed  and  per- 
fectly white. 

The  valve  and  inner  surface  of  the  caecum  presented  a slate-coloured  tint.  In 
the  colon  there  was  found  a great  number  of  small  follicles,  scarcely  projecting, 
but  easily  recognised  by  means  of  a black  point,  which  constituted  the  centre  of 
a slight  elevation,  where  the  mucous  membrane  was  of  a duller  white  colour,  an 
elevation  which  was  circumscribed  by  another  greyish  circle. 

In  one  point  of  the  colon  there  was  found  an  ulceration  which  appeared  to 
have  a tendency  to  cicatrise.  This  rounded  ulceration,  capable  of  containing  a 
five-sous  piece,  was  limited  by  a black  circle.  Its  bottom  was  on  a level  with 
the  rest  of  the  mucous  membrane  ; it  was  formed  by  a fine  membrane  similar  to 
the  membrane  of  the  sinuses,  in  which  was  seen  a vascular  network. 

The  spleen  was  not  large,  and  was  rather  soft.  The  liver  was  pale  and  dense. 
The  urinary  apparatus  was  healthy. 

Case  27. — Ataxo-adynamic  symptoms — Death  by  pneumonia  during  convalescence — Thin 
membrane,  without  follicles,  or  villi,  continuous  with  the  mucous  membrane,  in  the  points 
ordinarily  occupied  by  the  aggregated  follicles. 

We  did  not  see  during  his  life  the  individual  who  forms  the  subject  of  this 
case.  We  ascertained  that  having  entered  the  Charite  two  months  before,  he 
there  presented  all  the  symptoms  of  typhoid  fever;  that  he  was  completely  cured 
of  it,  and  that  he  was  on  the  point  of  leaving  the  hospital,  when  he  was  attacked 
with  pneumonia,  of  which  he  died. 

We  found  a mixture  of  red  and  grey  hepatisation  in  a great  part  of  the  left 
lung.  The  stomach  presented  a slight  arborisation  towards  its  great  cul-de-sac  ; 
this  same  arborisation  was  observed  in  several  points  of  the  small  intestine. 
Near  the  caecum  there  appeared  seven  or  eight  places  where  the  mucous  mem- 
brane was  much  thinner  than  elsewhere ; on  examining  it  under  water  in  the  sun, 
we  found  that  in  these  same  places  this  mucous  membrane,  which-appeared 
unusually  thin,  presented  no  trace  of  villosities,  which  were  very  numerous  in 
the  surrounding  parts  ; one  would  have  taken  it  for  a portion  of  the  bronchial 
mucous  membrane.  These  places  corresponded  to  those  which  are  occupied 
by  Peyer’s  patches.  We  thought  that  there  was  a period  of  the  disease  when 
those  patches  were  destroyed  ; that  at  a later  period  the  ulcers  which  had  suc- 
ceeded the  destruction  of  the  mucous  membrane  were  cicatrised,  and  that  the 
membrane  found  in  the  place  ordinarily  occupied  by  these  patches  was  a newly- 
formed  mucous  membrane,  a simple  cellulo-vascular  layer,  which  now,  however, 
was  continued  with  the  portions  of  the  mucous  membrane  which  had  formerly 
constituted  the  edges  of  the  ulcers.  Were  villosities  formed  afterwards  over 
this  new  membrane? 

7* 


78 


ANDRAL’S  MEDICAL  CLINIC. 


In  the  different  cases  which  we  have  hitherto  cited,  we  have  been  able  to  see 
the  dothinenterie  arise  with  the  fever,  continue  through  its  entire  course,  and 
cease  witli  it,  or  only  a mere  vestige  remain  after  it.  Why  then  should  we  not 
attribute  the  greatest  influence  in  the  production  of  the  symptoms  to  a lesion 
which  appears  and  disappears  with  them?  Yet  cannot  these  symptoms  exist 
only  when  there  is  dothinenterie?  The  following  cases  will  prove  the  contrary. 


ARTICLE  II. 

CONTINUED  FEVERS,  CONNECTED  WITH  OTHER  FORMS  OF  G ASTRO-INTESTINAL  IN- 
FLAMMATION THAN  FOLLICULAR  ENTERITIS. 

In  all  the  cases  included  under  this  article,  we  shall  still  find  the  different 
symptoms  which  the  cases  under  the  first  article  presented  to  us,  and  the  aggre- 
gate of  which  constitutes  the  ataxic  and  adynamic  fevers,  such  as  Pinel  has 
described  them.  But  in  some  of  these  cases  only,  we  shall  see  these  fevers 
present  the  same  course,  the  same  duration,  the  same  connexion  of  morbid  phe- 
nomena, as  in  those  which  are  connected  with  special  inflammation  of  the  intes- 
tinal follicles  ; they  will  still  be  typhoid  fevers,  in  the  sense  which  M.  Louis 
has  attached  to  the  term.  They  are,  no  doubt,  mere  exceptions,  and  it  remains 
no  less  true  that  the  typhoid  fever,  such  as  M.  Louis  has  described  it,  coincides 
almost  always  with  an  affection  of  Peyer’s  glands ; but  these  exceptions,  of  which 
M.  Louis  himself  has  published  two  cases,  h is  important  to  notice. 

This  fever,  which  is  characterised  less  by  the  symptoms  which  accompany  it, 
than  by  their  aggregate  and  by  the  manner  in  which  they  are  connected,  and 
succeed  each  other,  we  shall  no  longer  find  in  other  cases,  which,  however,  shall 
still  present  to  us  the  typhoid  state , or,  if  it  be  preferred,  those  same  ataxic  or 
adynamic  symptoms,  which  acquire  in  typhus,  properly  so  called,  their  maximum 
of  development. 

Case  28. — Delirium  and  other  nervous  symptoms — Tongue  natural — Numerous  ulcerations 
in  the  stomach — No  other  lesion. 

A shoemaker,  forty-five  years  old,  of  a very  strong  constitution,  entered  the 
Charite,  October  4th,  in  such  a state  of  delirium,  that  we  could  obtain  no  in- 
formation with  respect  to  his  previous  state. 

On  the  morning  of  the  5th,  we  observed  him  in  the  following  state ; eyes 
haggard,  sardonic  grin,  no  answer  to  questions.  Countenance  expressed  pain 
on  making  even  slight  pressure  on  any  point  whatever  of  the  abdomen  ; but  it 
also  expressed  it,  when  pressure  was  made  either  on  the  ribs,  or  the  extremities. 
Tongue  moist,  and  of  the  ordinary  appearance  ; no  stool  since  his  admission  ; 
breathing  free  ; pulse  sufficiently  full,  and  of  moderate  frequency  ; little  heat  of 
skin.  He  died  at  eight  o’clock  at  night. 

Post-mortem.  The  inner  surface  of  the  stomach  presented  along  the  great 
curvature  six  or  eight  small  superficial,  rounded  ulcerations,  with  red  bottoms, 
•their  diameter  being  on  an  average  that  of  a centime.  In  the  interval  between 
them  the  mucous  membrane  was  but  slightly  red. 

No  alteration  existed  in  the  rest  of  the  digestive  tube  ; it  presented  some  few 
red  patches.  Nothing  remarkable  in  any  of  the  other  organs. 

In  this  case,  as  in  several  of  the  preceding,  the  brain  appeared  to  be  the  origin 
of  all  the  symptoms  ; in  this  organ  the  primary  seat  of  the  disease  seemed  to 
be.  Still  the  brain  and  its  appendages  were  found  to  be  exempt  from  all  lesion, 
and  the  digestive  tube,  which  had  presented  no  functional  disturbance  during  life, 
was  the  only  part  found  altered  in  the  dead  body.  But  this  alteration  differs  very 


DISEASES  OF  THE  ABDOMEN. 


79 


much  from  those  seen  in  the  preceding  cases.  Peyer’s  patches  were  intact;  the 
small  intestine  as  well  as  the  large  was  healthy;  the  stomach  alone  was  diseased; 
and  what  is  very  remarkable  is  this,  that,  when  the  inner  surface  of  the  stomach 
was  studded  with  numerous  ulcerations,  the  tongue  presented  during  life  the  most 
natural  appearance. 

The  symptoms  presented  by  this  patient  differ  not  in  other  respects  from  those 
which  we  observed  in  a great  number  of  individuals,  in  whom  Peyer’s  glands 
were  especially  affected.  We  shall  again  find,  in  several  of  the  cases  which  are 
to  follow,  the  same  identity  of  symptoms  with  lesions  which  shall  always  reside 
in  the  digestive  tube,  but  which  shall  differ  considerably  from  each  other,  either 
in  their  seat  or  in  their  nature. 

Case  29. — Ataxic  symptoms;  alternations  of  delirium  and  of  perfect  intellect;  hydrophobia; 

convulsions — Tongue  natural ; pulse  not  frequent — Redness  in  different  points  of  the  diges- 

rive  tube — Injection  of  the  cerebral  substance — Pulmonary  tubercles. 

A man  twenty  years  of  age,  who  had  a cough  for  a year,  and  had  spit  blood 
several  times,  felt  general  illness  during  the  first  of  November^  On  the  10th,  he 
entered  the  Chari te.  He  coughed  very  much;  his  sputa  were  viscid,  a little 
bloody;  pulse  scarcely  frequent.  (He  was  bled  to  two  palettes.)  Blood  was 
not  buffed.  On  the  11th,  he  was  in  a state  of  torpor.  When  questioned,  he 
returned  no  answer;  when  raised,  he  fell  back  as  an  inert  mass,  and  hid  his  head 
under  the  clothes.  Pulse  was  remarkably  slow  ; countenance  very  pale;  tongue 
preserved  its  natural  appearance.  Some  symptoms  seemed  to  mark  the  com- 
mencement of  acute  hydrocephalus.  (Eight  leeches  were  applied  on  each  side 
of  the  neck  : sinapisms  ; barley.) 

Agitation  and  delirium  all  the  night.  In  the  morning  of  the  12th,  drowsi- 
ness ; pain  in  the  left  temple  ; right  pupil  perceptibly  more  dilated  than  the  left ; 
cheeks  a little  red  ; lies  on  the  right  side  ; tongue  white  and  moist ; breath 
foetid  ; abdomen  free  from  pain,  and  soft ; two  stools  ; pulse  46.  (Blisters  to 
the  legs  ; whey  with  the  addition  of  half  an  ounce  of  sulphate  of  soda  to  the 
pint.  The  following  mixture  to  be  taken  in  spoonfuls  ; — orange  flower  water, 
4 ounces;  mint  water,  1 ounce;  acetate  of  ammonia,  1 drachm  ( gros ) ; sulphu- 
ric ether,  1 drachm  ; syrup  of  violets,  2 ounces.) 

In  the  course  of  the  day  frequent  alternations  of  profound  stupor  and  violent 
agitation  ; no  stool. 

On  the  13th,  the  intellectual  faculties  were  alternately  lucid  and  very  much 
disturbed  ; the  inequality  of  dilatation  of  the  pupils  continued  ; the  respiration 
was  sometimes  very  slow,  sometimes  very  much  hurried  ; pulse  fifty-five  ; heat 
of  skin  moderate  ; the  face  became  red  and  pale  alternately.  (Lavement, 
with  the  addition  of  an  ounce  of  senna  and  six  grains  of  tartar  emetic  ; a pint 
of  veal  broth  with  half  an  ounce  of  sulphate  of  soda  ; aromatic  frictions  on  the 
extremities.)  Copious  stools  in  the  course  of  the  day. 

On  the  14th,  the  same  state.  On  the  15th,  the  patient  had  a sort  of  horror 
of  liquids.  'The  moment  any  thing  was  offered  to  him  to  drink,  his  face 
became  injected,  his  eyes  were  flushed,  his  lips  were  moved  convulsively ; 
and  if  a little  liquid  was  introduced  into  the  mouth,  he  threw  it  out  with  force  ; 
the  tongue  retained  its  moisture;  pulse  sixty.  (Two  more  blisters  to  the 
thighs.) 

On  the  16th,  the  symptoms  of  hydrophobia  of  the  preceding  day  no  longer 
existed  ; the  right  eye  was  forcibly  turned  inwards  ; the  pupil  of  this  eye  con- 
stantly remained  more  dilated  than  the  other,  the  left  eyelid  was  depressed  ; 
pulse  not  frequent.  (Emollient  ptisans  ; camphorated  lavement.) 

On  the  17th,  the  right  eyelid  was  now  paralysed  ; an  enormous  quantity  of 
urine  distended  the  bladder  ; great  talkativeness  ; subsultus  tendinum  ; tongue 
always  moist. 


80 


ANDltAL’S  MEDICAL  CLINIC. 


On  the  18th,  head  and  face  were  inundated  with  sweat,  whilst  the  skin  on 
the  rest  of  the  body  was  dry  ; the  eyes  were  closed  ; the  pupils,  very  much 
dilated,  scarcely  contracted  on  the  approach  of  light ; subsultus  tendinum  very 
much  increased;  face  very  red;  pulse  frequent  for  the  first  time  (101)  ; no 
stools.  (Purgative  lavement;  whey  with  tamarinds.) 

Profound  stupor  the  entire  day.  Death  without  a struggle  at  7 o’clock  at 
night. 

Post-mortem,  eighteen  hours  after  death.  Cranium.  — Cerebral  sinuses 
filled  with  blood,  cerebral  substance  of  ordinary  consistence,  marked  with  a 
considerable  quantity  of  red  points;  about  a spoonful  of  limpid  serum  in  each 
lateral  ventricle. 

Thorax.  — Old  adhesions  of  the  pleurte  on  both  sides  ; right  lung  studded 
with  miliary  tubercles  ; cavity  at  its  apex,  capable  of  lodging  a pigeon’s  egg, 
filled  with  pus.  In  the  left  lung,  equally  filled  with  crude  tubercles,  there  was 
a larger  cavity,  which  was  empty.  Heart  pale,  filled  with  liquid  blood. 

Abdomen. — Adhesion  of  the  great  epiploon  to  the  abdominal  parietes  by  old 
cellular  bands  ; the  stomach  presents  internally  to  the  left  of  the  cardia  a red 
patch,  broad  as  a three-franc  piece  ; every  where  else  the  mucous  membrane  is 
white  and  healthy  ; most  of  the  valves  of  the  duodenum  were  of  a bright  red 
colour;  in  the  intervals  between  them  the  mucous  membrane  presents  a rose 
tint.  The  small  intestine,  opened  through  its  entire  extent,  presented  here  and 
there,  towards  its  middle  part,  merely  some  reddish  valves  and  a few  arborisa- 
tions. Invagination  of  three  inches  of  the  upper  third  of  the  jejunum  ; a con- 
siderable quantity  of  bile  filled  all  the  small  intestine.  The  large  intestine,  filled 
with  hard  faecal  matters,  was  very  white. 

An  enormous  quantity  of  limpid  urine  distended  the  bladder,  as  well  as  the 
ureter,  pelvis,  and  calices  of  the  right  kidney. 

In  this  subject  we  find  very  slight  lesions  in  the  digestive  tube.  The  red 
patch,  in  the  great  cul-de-sac  of  the  stomach,  the  redness  of  the  valves  of  the 
duodenum,  the  slight  injection  of  some  points  of  the  small  intestine,  are  ob- 
served in  many  cases  where,  during  life,  symptoms  altogether  different  have 
existed  ; thus  we  think  that  here  there  are  strong  reasons  to  doubt  that  very 
slight  lesions  found  in  the  digestive  lube  were  really  the  cause  of  the  ataxic 
symptoms  observed  during  life.  Can  the  injection  of  the  brain  account  for 
them?  That  also  may  be  doubted. 

In  this  case,  as  in  the  preceding,  the  tongue  appeared  very  different  from 
what  we  have  found  it  in  most  of  the  cases  of  dothinenteries,  which  form  the 
subject  of  the  observations  contained  in  the  preceding  article. 

Let  us  remark  also  how  varied  the  symptoms  were  : among  those  symptoms 
we  may  recollect  the  inequality  in  the  dilatation  of  the  pupils,  the  temporary 
deviation  of  one  of  the  eyes,  the  alternate  paralysis  of  the  two  upper  lids,  the 
rapid  transition  from  lucid  intellect  to  complete  delirium,  from  profound  coma 
to  the  most  violent  agitation  ; the  well-marked  hydrophobia  which  existed  for 
twelve  hours.  On  the  part  of  the  functions  of  organic  life,  we  should  recollect 
the  respiration  sometimes  accelerated  and  sometimes  very  slow  ; the  disturbance 
of  the  circulation  marked  in  the  small  vessels  by  the  quick  alternations  of  red- 
ness and  paleness  of  the  face,  in  the  heart  and  great  arterial  trunks,  by  the  ex- 
treme slowness  of  the  pulse;  the  bladder  struck  with  paralysis  ; the  muscular 
fibres  of  the  large  intestine,  which  had  also  become  insensible  to  the  action  of 
purgatives  ; in  the  midst  of  all  these  disturbances  the  tongue  remaining  in  its 
natural  state. 

The  treatment  was  directed  exclusively  against  the  cerebral  symptoms.  I3y 
perusing  the  details  of  the  case,  it  may  be  seen  how  far  these  symptoms  were 
influenced  : — 1st,  by  the  two  bleedings  employed  towards  the  commencement. 
2dly,  by  the  blisters  applied  to  different  points  of  the  cutaneous  surface.  3dly, 


DISEASES  OF  THE  ABDOMEN. 


SI 


by  several  stimulating  substances,  called  antispasmodics,  administered  by  the 
mouth,  or  in  the  form  of  lavement.  4thly,  by  the  purgatives  taken  several 
times  into  the  digestive  tube,  sometimes  by  the  stomach,  sometimes  by  the 
rectum. 

Case  30. — Fever  at  the  commencement ; epigastric  pain  ; vomiting — Subsequently  symptoms 
of  tetanus  and  death — Intense  redness  of  the  stomach. 

A middle-aged  man  was  seized,  without  any  known  cause,  four  days  before 
entering  the  hospital,  with  profuse  bilious  vomiting,  pain  in  the  epigastrium 
and  fever.  About  twenty  hours  after  the  appearance  of  these  symptoms,  this 
person  began  to  feel  some  difficulty  in  depressing  the  jaw  ; violent  trismus  soon 
set  in,  and  continued  for  the  two  following  days.  Having  entered  the  Charite 
at  the  end  of  this  time,  he  presented  the  following  state: 

Trismus.  Head  relroverted  and  kept  in  this  position  by  the  muscles  inserted 
into  the  occipital  bone  ; rigidity  of  the  four  extremities  ; abdominal  parietes 
hard  as  a board  ; intellect  intact.  The  patient  himself  detailed  to  us  the  par- 
ticulars now  described : he  articulates  distinctly  enough,  notwithstanding  the 
trismus.  He  no  longer  experiences  any  pain  in  the  epigastrium,  and  did  not 
vomit  since  the  appearance  of  the  first  tetanic  symptoms.  After  the  visit  he 
was  removed  into  the  surgical  wards,  and  died  there  that  same  night. 

Post-mortem.  Cranium.  — Slight  injection  of  the  membranes;  some  red 
dotting  of  the  cerebral  substance.  The  different  parts  of  the  encephalon,  ex- 
amined with  the  utmost  care,  presented  no  appreciable  alteration.  Spine.  — 
Sound  state  of  the  spinal  marrow  and  of  its  membranes,  which  were  pale. 

Abdomen.  — The  gastric  mucous  membrane  presents  through  its  entire  extent 
an  intensely  red  colour,  which  is  not  perceptible  until  a thick  layer  of  mucus 
which  lines  the  surface  has  been  removed.  This  colour,  which  resides  in  the 
mucous  membrane,  is  owing  to  the  injection  of  an  immense  number  of  small 
vessels,  the  beautiful  anastomoses  of  which  may  be  readily  traced  by  the  eye. 
The  membrane  is  not,  in  other  respects,  perceptibly  softened.  The  rest  of  the 
digestive  tube  white.  The  tissue  of  the  spleen  remarkable  for  its  consistence. 

We  have  seldom  seen  in  the  stomach  so  intense  and  so  extensive  a red 
colouring ; one  would  have  said  at  first,  that  the  inner  surface  of  the  stomach 
had  been  uniformly  tinged.  The  mucous  membrane  thus  coloured  had  re- 
tained its  physiological  consistence  ; only  its  habitual  secretion  seemed  to  have 
been  increased. 

The  onset  of  this  gastritis  had  been  well-marked  ; but  the  tetanic  symptoms 
had  scarcely  commenced  to  show  themselves,  when  the  symptoms  referable  to 
the  stomach  became  much  less  evident. 

If  the  tetanus  was,  in  this  individual,  the  result  of  irritation  transmitted  sym- 
pathetically from  the  stomach  to  the  spinal  cord,  there  must  be  admitted  to 
exist  in  this  person  a special  predisposition,  in  virtue  of  which  tetanus  would 
have  equally  declared  itself,  no  matter  what  organ  had  become  the  seat  of  irri- 
tation. Thus  we  remember  to  have  seen  at  the  Charite  an  individual  labouring 
under  chronic  pleuritis,  who,  after  the  application  of  a seton  on  the  chest,  was 
attacked  with  tetanus,  of  which  he  died. 

Case  31. — Symptoms  of  acute  meningitis  (ataxic  fever) — Tongue  natural — Profuse  blood- 
letting— Intense  injection,  in  several  points,  of  the  mucous  membrane  of  the  lower  third  of 
the  small  intestine. 

A man,  thirty-three  years  of  age,  black  hair,  brown  skin,  muscles  well  de- 
veloped, felt,  on  the  8th  of  October,  a weight  of  head  more  inconvenient  than 
painful.  In  the  evening  there  was  general  uneasiness  ; delirium  at  night.  He 
entered  the  Charite  on  the  9th.  When  seen  by  the  clinical  clerk,  he  was 


82 


ANDRAL’S  MEDICAL  CLINIC. 


rational;  but  lie  complained  of  dizziness,  of  tinnitus  aurium  ; some  purging 
since  morning.  At  night  he  raved  again. 

At  the  visit  of  the  10th,  he  presented  the  following  state  : remarkable  exal- 
tation in  his  ideas  ; great  loquacity  ; still  his  answers  were  clear  and  precise ; 
extreme  activity  in  his  movements  ; face  red  ; expression  of  the  eyes  natural ; 
pulse  full,  very  hard,  moderately  frequent;  temperature  of  the  skin  natural; 
tongue  moist  and  clean  ; abdomen  soft,  and  free  from  pain.  Three  liquid 
stools  the  last  twelve  hours. 

In  this  individual  the  brain  seemed  to  be  the  seat  of  a sanguineous  conges- 
tion, indicated,  at  present  particularly,  by  the  exaltation  of  the  intellect,  and 
at  night  by  its  perversion.  (Bleeding  to  three  palettes  ; diluent  ptisans.)  No 
change  in  the  course  of  the  day  ; two  or  three  stools.  In  the  evening  and  at 
night  there  was  acceleration  of  the  pulse,  return  of  the  delirium, 

On  the  morning  of  the  11th,  reason  returned,  and  we  found  the  patient  in 
the  same  state  as  at  the  visit  of  the  10th.  (Another  bleeding  to  the  extent  of 
three  palettes  ; sixteen  leeches  to  the  neck.)  The  blood  of  both  bleedings  was 
covered  with  a thick  bufly  coat. 

In  the  evening  there  was  delirium,  as  on  the  preceding  days  ; at  night  the 
patient  became  furious  ; he  broke  the  cords  with  which  he  had  been  tied,  and 
four  men  could  scarcely  hold  him.  On  the  morning  of  the  12th,  the  delirium 
continued.  The  patient  lying  on  his  back;  face  very  much  injected  ; eyes 
sparkling  and  rolling  violently  in  the  orbits  ; he  uttered  continual  cries  ; in  the 
midst  of  his  delirium  he  spoke  only  of  objects  connected  with  his  state  ; profuse 
sweat  poured  from  the  skin  of  the  cranium  and  face  ; the  rest  of  the  skin  was 
dry.  The  constant  movements  of  the  arms  did  not  allow  us  to  ascertain  the 
state  of  the  pulse.  The  tongue  retained  its  natural  appearance.  Such  was 
the  state  of  the  patient  at  eight  o’clock  in  the  morning.  (Thirty  leeches  to  the 
neck  ; bleeding  from  the  arm.)  One  hour  after,  at  nine  o’clock,  the  blood  from 
the  leech  bites  flowed  profusely;  venesection  was  performed,  notwithstanding 
the  violent  resistance  of  the  patient.  However,  no  improvement  occurred  : at 
half  past  nine  again  he  exerted  great  muscular  strength  ; we  heard  his  voice  at 
more  than  fifty  paces  from  the  bed ; all  at  once  he  ceased  to  vociferate  ; his 
face  became  injected  and  swollen  ; his  extremities  rigid;  his  respiration  was 
arrested  ; and  in  less  than  five  minutes  he  expired. 

Post-mortem.  Pia  mater  of  the  convexity  of  the  brain  but  slightly  injected. 
Small  quantity  of  limpid  serum  in  the  ventricles,  such  as  is  seen  after  all  kinds 
of  death.  The  cerebral  substance,  when  sliced,  preserved  everywhere  its 
natural  consistence,  but  it  presented  everywhere  a great  number  of  small  red 
points,  from  which  blood  flowed.  Neither  the  spinal  cord,  examined  through 
its  entire  extent,  nor  its  membranes,  presented  any  appreciable  lesion. 

The  lungs  were  healthy.  The  heart  presented  remarkable  dilatation  of  the 
left  ventricles,  without  hypertrophy  of  its  parietes. 

The  inner  surface  of  the  stomach  was  white,  as  also  that  of  the  small  intes- 
tine, as  far  as  the  union  of  its  upper  two-thirds  with  its  lower  third.  In  this 
latter  third  there  were  observed  numerous  red  spots,  seated  in  the  mucous 
membrane,  which  in  other  respects  appeared  neither  denser,  softer,  nor  thicker 
than  in  the  interval  between  those  spots,  where  it  was  white.  Thus,  these 
spots  represented  a multitude  of  circumscribed  inflammations,  none  of  which 
had  passed  the  first  stage,  or,  in  other  words,  that  wherein  there  is  as  yet  only 
injection  of  the  mucous  membrane,  without  thickening  or  softening  of  its  sub- 
stance. Large  intestine  white. 

In  the  individual  whose  case  is  here  given,  the  cerebral  symptoms  were  so 
predominant,  that  they  seemed  to  announce  an  idiopathic  lesion  of  the  ence- 
phalon ; and  particularly  a well-marked  lesion  of  the  membranes.  The  nature 
of  the  phenomena,  the  continual  exaltation  of  his  ideas  with  intermittent  deli- 


DISEASES  OF  THE  ABDOMEN. 


83 


rium,  and,  in  the  last  stage,  a furious  delirium,  seemed  even  to  indicate  that 
this  inflammation  had  its  site  particularly  in  the  arachnoid  which  covers  the 
convexity  of  the  cerebral  hemispheres  ; yet  no  arachnitis  existed,  and  the  ex- 
tremity of  the  small  intestine  alone  presented  an  inflammation  which,  during 
life,  had  not  been  disclosed  by  other  signs  than  a very  slight  diarrhcea.  It 
now  remains  to  be  determined  whether  this  inflammation,  sympathetically  irri- 
tating the  brain,  occasioned  the  frightful  group  of  nervous  symptoms  which 
brought  the  patient  to  the  grave.  1 shall  content  myself  with  stating  the  fact, 
leaving  the  reader  at  liberty  to  admit  or  reject  this  connection  between  the  in- 
testinal inflammation  and  the  cerebral  symptoms  : it  is  because  this  case  is  so 
very  marked,  that  I thought  it  deserving  of  some  interest.  I shall  once  more 
call  attention  to  the  manner  in  which  death  supervened.  Here  death  struck 
the  patient  suddenly,  when  the  vital  energy  was  still  very  great,  and  it  was,  in 
a manner,  without  any  intermedium,  that  life  was  arrested  in  him.  Would  it 
not  appear  that,  in  this  case,  the  sinking  of  the  brain  succeeding  its  excess  of 
action  suddenly,  the  suspension  of  the  breathing,  and  consequently  of  all  the 
functions,  was  the  result  of  the  sudden  and  complete  cessation  of  the  nervous 
influence  ? Let  us  not  strive  to  search  too  deeply  for  the  cause  of  these  phe- 
nomena, which  a century  back  would  have  been  accounted  for  very  differently, 
and  which  will  one  day  probably  be  explained  in  a manner  just  as  different  as 
that  in  which  we  now  explain  it,  whether  in  consequence  of  additional  know- 
ledge being  acquired,  or  by  reason  of  the  prevailing  medical  opinions. 

Some  of  the  cases  now  given  entirely  resemble  those  where  there  was  dothin- 
enterite,  in  the  existence  of  nervous  disturbances  ; in  them,  however,  the  symp- 
toms called  ataxic  are  much  more  prominent  than  those  called  adynamic  ; in 
them  also  the  tongue  scarcely  deviated  from  its  natural  state  ; we  have  also  seen 
this  natural  state  of  the  tongue  retained  in  some  cases  of  dothinenterite,  but  much 
more  rarely.  In  these  cases  the  abdomen  was  not  tympanitic,  but  we  have  seen 
this  phenomenon  wanting  also  in  many  individuals  affected  with  dothinenterite* 
Here  now  are  two  other  cases  in  which  this  latterphenomenon  was  also  wanting, 
as  well  as  in  the  preceding,  and  still  where  the  symptoms  were  much  more  com- 
pletely those  observed  in  dothinenterite. 

Case  32. — Symptoms  of  typhus  ; tongue  dry  and  black  only  at  intervals;  tympanitic  state  of 
the  abdomen  towards  the  end — Alternations  of  quick  excitement  and  great  depression — - 
Blisters;  camphor  in  lavement ; wine  and  broth  ; ice  to  the  head — Death  towards  the  20th 
day — Partial  redness  of  the  gastro-intestinal  mucous  membrane — Injection  of  the  cerebral 
substance  and  of  the  membranes — Spleen  large  and  soft ; liquid  blood  in  the  heart. 

A man,  about  thirty  years  of  age  with  black  hair,  brown  skin,  strong  make, 
with  considerable  embonpoint,  was  brought  to  the  Charite  on  the  27th  of  Feb- 
ruary, in  such  a state  that  we  could  obtain  no  information  regarding  his  previous 
history  : we  merely  ascertained  that  he  was  sick  for  the  last  fifteen  days  ; that 
on  the  23d  of  February  he  had  taken  a vomit,  and  that  the  day  afterleeches  were 
applied  to  the  epigastrium.  25th,  he  had  ceased  to  speak.  Brought  to  the  hos* 
pital  on  the  27th  ; he  answered  no  questions  ; features  were  expressive  of  great 
stupor;  skin  cold;  pulse  scarcely  perceptible;  small  rose-coloured  spots,  most 
of  them  being  from  half  a line  to  three  lines  in  diameter,  were  scattered  in  con- 
siderable number  over  the  antertor  part  of  the  chest  and  abdomen,  also  on  the 
upper  and  lower  extremities.  They  were  fewer  on  the  extremities  than  on  the 
trunk.  We  could  see  only  the  extremity  of  the  tongue,  which  appeared  very 
dry;  the  abdomen  was  soft ; no  stool  since  he  entered  the  hospital.  (Wine* 
whey;  frictions  of  the  extremities  with  volatile  liniment  and  cantharides  ; two 
blisters  to  the  legs  ; lavement  of  marsh-mallow  with  the  addition  of  a scruple  of 
camphor.) 


84 


ANDItAL’S  MEDICAL  CLINIC. 


Iti  the  course  of  the  day  the  patient  uttered  some  unconnected  unintelligible 
words.  Ilis  bladder  was  filled  with  urine  ; he  was  sounded  twice. 

The  next  day,  28th,  his  countenance  had  a cadaverous  paleness.  Unconscious 
of  everything  which  passed  around  him,  he  seemed  to  reflect : his  features  were 
immoveable.  When  questioned,  he  did  not  answer  at  first ; some  minutes  after, 
he  seemed  to  come  to  himself,  and  answered  slowly,  but  accurately — he  then 
relapsed  into  his  former  state.  He  lay  on  his  back,  with  his  arms  extended 
along  the  trunk.  The  eruption  more  confluent  than  the  day  before.  Frequent 
subsultus  ; skin  a little  warm  ; pulse  improved  ; it  was  very  frequent,  very  com- 
pressible, and  intermittent  at  intervals.  The  tongue,  which  he  was  unable  to 
put  out,  though  desirous  to  do  so,  was  smooth  and  dry  at  its  apex,  and  covered 
with  a blackish  coat  at  its  upper  surface:  one  stool.  Abdomen  still  soft; 
paralysis  of  the  bladder  remained.  (Same  prescription.) 

In  the  night  the  physical  and  moral  torpor  was  succeeded  by  violent  delirium, 
during  which  the  patient  sat  up,  and  attempted  to  escape  from  the  bed. 

On  the  morning  of  March  1st,  he  was  seen,  from  time  to  time,  to  sit  up,  look 
around  him  with  an  astonished  air,  then  lie  down  again  ; he  spoke  not  a word, 
nor  did  he  seem  to  hear  those  who  interrogated  him,  and  appeared  to  direct  his 
whole  attention  to  some  one  fixed  idea.  The  tongue  was  red  and  moist ; no 
stool ; even  the  lavement  had  not  been  discharged  ; subsultus  tendinum  dimin- 
ished. The  patient  passed  no  urine  for  more  than  twelve  hours  ; yet  the  bladder 
was  empty.  The  eruption  was  in  the  same  state.  (Wine-whey;  liniment  as 
before  ; six  grains  of  calomel  in  two  packets  ; broth.) 

March  2d.  Convulsive  movements  of  the  muscles  of  the  face;  great  redness 
of  the  cheeks  succeeded  the  cadaverous  paleness  ; the  eyes  haggard,  rolled 
violently  in  their  orbits  ; the  lower  jaw  was  continually  moving  ; the  muscles  of 
the  extremities  were  spasmodically  contracted  ; patient  uttered  some  uncon- 
nected words;  tongue  red  and  moist,  lips  and  teeth  rather  dark,  deglutition  painful, 
abdomen  a little  tympanitic  ; two  stools  ; pulse  could  not  be  felt,  in  consequence 
of  the  very  frequent  subsultus  ; profuse  sweat  covered  the  skin  ; the  petechiae 
were  less  numerous  and  pale.  (Application  of  ice  to  the  head,  and  at  the  same 
time  sinapisms  to  the  feet.) 

In  the  course  of  the  day  the  convulsive  movements  ceased. 

On  the  3d,  great  prostration  succeeded  the  violent  agitation  of  the  day 
before  ; the  petechiae  were  livid,  face  still  injected,  tongue  again  dry  and  brown  ; 
the  dark  coat  of  the  lips  and  teeth  very  thick;  the  respiration,  hitherto  calm, 
was  very  frequent  and  loud,  the  expiration  was  shorter,  inspiration  more  pro- 
longed : pulse  now  thready,  cannot  be  counted  ; the  skin,  which  was  moist, 
seemed  to  the  touch  as  it  were  covered  with  a thick  layer  of  oil. 

He  died  in  the  evening. 

Post-mortem,  seventeen  hours  after  death.  The  membrane  of  the  convexity 
of  the  hemispheres  were  very  much  injected,  each  lateral  ventricle  contained 
from  three  to  four  tea-spoonsful  of  limpid  serum  ; there  was  a little  also  at  the 
base  of  the  cranium  and  in  the  spinal  canal.  The  white  substance  of  the  upper 
part  of  the  hemispheres  was  marked  with  a great  number  of  small  red  points. 

The  lungs  were  perfectly  healthy,  scarcely  engorged  ; the  heart  contained  a 
small  quantity  of  liquid  black  blood. 

The  stomach  was  of  the  ordinary  size,  the  mucous  membrane  of  its  splenic 
portion  was  studded  with  a number  of  small  reddish  points  ; the  duodenum  was 
pale  ; the  small  intestine,  in  its  upper  two-thirds,  presented  a slight  rose-coloured 
tint;  the  lower  third  was  a livid  red  colour,  and  forcibly  contracted.  The 
large  intestine,  through  all  its  extent,  was  perfectly  white.  The  spleen  was 
remarkably  large  and  soft. 

All  the  symptoms  observed  in  the  individuals  affected  with  dothinenterite, 
are  found  in  the  patient  whose  history  lias  been  now  given  : however,  the 


DISEASES  OF  THE  ABDOMEN. 


S5 


post-mortem  detected  in  him  no  trace  of  an  affection  of  the  intestinal  follicles ; 
there  was  nothing  but  an  erytheme  of  different  points  of  the  gastro-intestinal 
mucous  membrane ; and  it  must  be  said,  this  erytheme  was  not  more  considerable 
than  that  met  with  in  many  other  cases,  where  morbid  states  altogether  different 
have  been  observed  during  life,  and  particularly  where  the  tongue  has  been 
neither  dry  nor  black. 

With  this  different  alteration  of  the  digestive  tube,  we  meet  the  very  same 
state  of  the  spleen  as  in  individuals  affected  with  dothinenterite. 

The  brain  and  membranes  are  the  seat  of  considerable  injection ; but  what 
importance  are  we  to  attach  to  a lesion  whose  existence  is  so  inconstant  in 
cases  where  the  same  functional  disturbances  have  existed  ? 

The  individual  who  forms  the  subject  of  this  case  was  distinguished  from 
several  of  the  preceding  by  his  strong  make,  his  well  developed  muscles,  and 
his  embonpoint.  As  others,  however,  who  presented  physiological  conditions 
quite  opposite,  he  presented  the  signs  of  great  prostration  when  he  entered  the 
hospital ; but  these  signs  soon  disappeared,  and  those  of  great  excitement  of 
the  nervous  system  appeared  ; finally,  twenty-four  hours  before  death,  the 
prostration  again  became  the  prevailing  symptom.  It  seems  then  that  we  can 
understand  better  how  life  terminates  than  in  some  other  cases  above  cited, 
where  death  suddenly  struck  the  patients  in  the  midst  of  great  agitation,  and 
when  they  still  give  proof  of  their  strength  by  the  violence  of  their  cries  and 
by  the  energy  of  their  muscular  movements. 

Among  the  remarkable  phenomena  of  this  disease,  we  shall  notice  the  petechial 
eruption,  which  faded  away  according  as  the  disease  proceeded  towards  a fatal 
termination  ; the  sweats  which  took  place  towards  the  latter  period,  and  which 
afforded  no  relief ; the  pale  and  livid  tint  of  the  face,  and  subsequently,  its 
bright  red  injection  ; the  pulse,  which  continued  very  weak,  an4  became  more 
and  more  frequent ; the  temperature  of  the  skin,  which  was  never  but  mode- 
rately raised  ; the  tongue,  which,  dry  and  brown  during  the  two  adynamic 
stages,  became  clean  and  moist  during  the  stage  of  excitement ; in  fine,  the 
paralysis  of  the  bladder,  and,  at  a later  period,  the  cessation  even  of  the  urinary 
secretion. 

Case  33. — Acute  gastritis  developed  after  the  use  of  a large  dose  of  tartar  emetic — Tongue 
dry  and  black ; tympanitic  state  of  the  abdomen  ; state  of  adynamia. 

A man,  fifty-two  years  of  age,  entered  the  Hopital  de  la  Pitie  with  all  the 
symptoms  of  well-marked  pneumonia.  He  was  first  bled  ; then  we  commenced 
with  him  the  use  of  tartar  emetic,  of  which  we  gave  him  six  grains  the  first 
day  and  twelve  the  second  day,  in  three  glasses  of  infusion  of  orange  leaves,  to 
which  was  added  half  an  ounce  of  syrup  of  diacodium.  At  the  time  the  patient 
commenced  the  use  of  tartar  emetic,  the  digestive  passages  presented  no  signs 
of  softening  ; the  tongue  was  moist  and  whitish  ; there  was  neither  thirst, 
vomiting,  or  nausea ; the  abdomen  was,  in  every  part,  soft  and  free  from  pain  ; 
scarcely  a single  stool  occurred  every  two  dSys. 

The  day  after  he  took  six  grains  of  tartar  emetic,  he  presented  no  symptom 
connected  with  the  digestive  passages  ; they  appeared  to  us  in  the  same  state 
as  the  day  before  ; some  nausea  took  place,  without  vomiting.  The  signs  of 
pneumonia  in  the  second  stage  continued  in  all  their  intensity. 

We  now  doubled  the  dose  of  tartar  emetic,  as  we  did  in  many  other  cases, 
without  any  unpleasant  consequences. 

On  the  same  day,  profuse  vomiting  came  on,  and  purging  also  took  place. 

When  we  re-visited  the  patient,  the  vomiting  continued  as  well  as  the  diar- 
rhoea ; the  tongue,  till  then  natural,  became  red  and  dry.  He  complained  of  an 
acute  pain  in  the  epigastrium,  which  was  increased  by  pressure.  The  use  of 
tartar  emetic  was  discontinued.  However,  during  the  twenty-four  hours  fol- 


86 


ANDRAL’S  MEDICAL  CLINIC. 


lowing,  the  vomiting  continued ; it  then  ceased,  not  to  reappear  ; but  the  diges- 
tive passages  remained  affected,  and,  during  the  six  following  days,  we  wit- 
nessed the  development  of  still  more  serious  symptoms. 

Thus,  the  tongue  becomes  covered  with  a black  coat,  the  lips  and  teeth  be- 
come blackish.  The  abdomen  becomes  distended  to  such  a degree  that  the 
course  of  the  colon  may  be  traced  through  the  abdominal  parietes  .;  four  or  five 
stools  took  place  every  day.  The  countenance  acquired  a leaden  hue,  and 
presented  an  air  of  most  marked  stupor.  Soon  after  the  patient  no  longer  an- 
swers questions  ; he  is  in  a low  muttering  delirium  ; all  his  features  are  immove- 
able ; some  subsultus  tendinum  is  perceived  ; the  prostration  becomes  more  and 
more  considerable.  The  pulse  acquires  constantly  increasing  frequency,  and 
death  takes  place  twenty  days  after  the  invasion  of  the  pneumonia. 

Post-mortem.  All  the  left  lung,  except  at  its  apex,  presented  a combination 
of  red  and  grey  hepatisation. 

The  stomach  was  contracted,  and  its  inner  surface  lined  with  a greyish 
mucus.  Beneath  this  mucus  it  presented  through  its  entire  extent  a slate-co- 
loured ground,  surmounted  by  an  intensely  red  dotting;  attentive  examination 
soon  showed  that  this  dotting  resulted  from  a fine  and  general  injection  of  the 
villosities.  At  the  same  time  that  it  is  thus  coloured,  the  mucous  membrane 
underwent  considerable  thickening  ; far  from  being  softened  in  any  of  its  points, 
it  was  every  where  as  if  indurated,  and  had  a granulated  appearance.  The 
valves  of  the  duodenum  were  of  a bright  red  colour.  The  small  intestine  pre- 
sented nothing  but  slight  injection  of  its  mucous  membrane  to  the  extent  of  a 
foot  above  the  ileo-c83cal  valve.  No  follicle  was  discovered  in  this  intestine. 
The  caecum  participated  in  the  injection  of  the  end  of  the  small  intestine.  The 
mucous  membrane  of  the  colon  presented  a number  of  red  bands,  between  which 
it  was  white  and  of  the  natural  consistence. 

The  liver,  considerably  gorged  with  blood,  presented  nothing  abnormal  in 
other  respects. 

If  Pinel  were  to  give  a name  to  the  disease  which  forms  the  subject  of  the 
case  now  read,  he  would  have  called  it  adynamic  fever  supervening  during 
the  course  of  a pneumonia.  In  fact,  all  the  symptoms  characteristic  of  this 
fever  are  to  be  found  here.  Yet,  is  it  the  disturbance  of  the  nervous  system 
which  here  opens  the  scene  ? By  no  means.  It  is  in  the  digestive  passages 
that  the  symptoms  evidently  commence  (redness  and  dryness  of  the  tongue  ; 
profuse  evacuations  up  and  down ; epigastric  pains).  Then  of  these  phe- 
nomena none  remain  save  the  redness  of  the  tongue,  and  a little  diarrhoea ; but 
it  is  then  that  the  symptoms  called  adynamic  appear.  All  these  disturb- 
ances succeed  the  use  of  the  tartar  emetic  so  suddenly,  we  so  plainly  perceive 
the  several  phenomena  set  out  from  the  digestive  passages,  that  we  can  scarcely 
refuse  to  consider  that  the  employment  of  the  tartar  emetic  was  the  cause  of 
them.  To  this,  no  doubt,  it  will  be  said  that  in  a thousand  other  cases  nothing 
similar  is  observed  ; we  grant  it,  but  we  also  know  that  there  are  particular  dis- 
positions which  render  very  dangerous  the  administration  of  large  doses  of  tartar 
emetic,  though,  under  ordinary  circumstances,  it  may  be  harmless. 

A short  time  since,  for  instance,  we  saw  a man,  forty-eight  years  of  age,  at- 
tacked with  a severe  pneumonia,  which  had  arrived  at  the  stage  of  hepatisation, 
who  was  made  to  take,  in  divided  doses,  only  six  grains  of  tartar  emetic  in  a six 
ounce  mixture.  Before  the  administration  of  this  medicine  had  been  com- 
menced, the  digestive  passages  appeared  to  be  in  a healthy  state  ; the  tongue 
was  moist  and  pale  ; we  ascertained  from  the  previous  history  that  the  patient 
had  habitually  good  digestion.  After  the  first  few  spoonfuls  of  the  emetic  solu- 
tion, vomiting  appeared  ; hopes  were  ascertained  that  tolerance  would  be  esta- 
blished, as  happens  in  many  cases  ; and  the  medicine  was  continued  ; but  quite 
the  contrary  result  took  place  ; the  vomiting  became  more  and  more  frequent ; 
the  tongue,  previously  pale  and  moist,  became  red  and  dry  as  a bit  of  parch- 


DISEASES  OF  THE  ABDOMEN. 


87 


ment ; the  two  following  days  the  patient  did  not  pass  a quarter  of  an  hour 
without  the  vomiting  being  renewed  ; nothing  could  stop  it,  and  he  died  from 
the  exhaustion  consequent  on  it.  The  body  was  not  examined  after  death. 

The  case  which  suggests  to  us  these  reflections,  presents  then  a well-marked 
example  of  what  is  called  adynamic  fever,  produced  by  an  acute  inflammation 
of  the  stomach.  Is  this  typhoid  fever?  No  ; it  is  not  in  the  order  and  suc- 
cession of  the  symptoms  of  the  pyrexia  which  has,  for  its  anatomical  character, 
inflammation  of  Peyer’s  glands  ; but  with  respect  to  the  nature  of  the  symp- 
toms is  it  not  a disease  of  the  same  family  ? It  is  a gastritis,  in  consequence 
of  which  adynamic  symptoms  become  developed. 


ARTICLE  Hi, 

OBSERVATIONS  ON  CASES  OF  DIFFERENT  DISEASES  ACCOMPANIED  WITH 

TYPHOID  SYMPTOMS,  WITHOUT  APPRECIABLE  LESION  OF  THE  DIGES- 
TIVE TUBE. 

As  often  as,  after  having  observed  the  two  morbid  groups  designated  by 
nosographists  under  the  name  of  bilious  and  mucous  fever,  we  have  been  able 
to  examine  the  state  of  the  organs  in  the  dead  body,  we  have  met  lesions  in 
the  digestive  passages,  which  have  explained  at  least  a part  of  the  symptoms 
observed  during  life.  Such  was  not  always  the  case  with  the  individuals  who 
presented  to  us  those  different  groups  of  morbid  phenomena  designated  by  the 
names  of  inflammatory,  adynamic,  or  ataxic  fever.  In  these  cases  we  have  very 
often  found  lesions  of  the  digestive  tube,  which  the  preceding  observations  induced 
us  to  expect;  but  very  often  also  we  have  been  unable  to  establish  any  relation 
between  the  intensity  of  these  lesions  and  the  severity  of  the  symptoms  ; so  that, 
for  instance,  in  the  digestive  tube  of  an  individual  who  died  during  the  course 
of  a slight  bilious  fever,  we  found  an  alteration  equal  in  its  nature  and  intensity 
to  that  which  we  detected  in  the  intestine  of  another  individual  who  died  with 
the  very  worst  symptoms  of  an  ataxo-adynamic  fever.  The  preceding  obser- 
vations equally  establish  the  same  thing.  If  such  be  the  case,  is  it  not  reasonable 
to  think  that  the  different  lesions  which  anatomy  discovers  in  the  digestive  tube 
of  patients  who  die  during  the  course  of  a bad  fever,  are  not  the  sole  cause  of 
it  ? Should  it  not  be  laid  down  that  the  adynamic  or  ataxic  phenomena  depend 
much  less,  in  these  cases,  solely  on  the  nature  or  intensity  of  the  intestinal 
lesion,  than  on  the  disposition  in  which  this  lesion,  slight  or  severe,  finds  the 
innervation?  If  now  these  different  phenomena  called  adynamic  ©r  ataxic,  are 
observed  in  cases  where,  on  opening  the  bodies,  we  find  the  digestive  tube 
healthy,  and  other  organs  the  seat  of  lesion,  will  not  the  proposition  now  stated 
be  found  singularly  confirmed  by  such  facts,  and  shall  we  not  be  warranted  in 
saying  that  the  symptoms  called  adynamic  or  ataxic  are  the  result  of  a disturb- 
ance in  the  action  of  the  nervous  centres,  a disturbance  sometimes  primary,  and 
which  may  then  exist  with  a lesion  appreciable  on  opening  the  body  ; but  most 
frequently  consecutive,  and  then  developed  in  consequence  of  the  lesion  of  some 
organ,  of  the  digestive  tube,  as  of  any  other  ? The  following  cases  go  to  prove 
the  correctness  of  this  mode  of  viewing  the  subject : — 

These  eases  constitute  two  series  : in  some  the  typhoid  symptoms  coincide 
with  lesions  of  different  organs,  which  may  be  considered  as  their  origin  ; these 
lesions  are  at  least  the  occasion  of  their  development.  In  the  other  cases  these 
lesions  themselves  no  longer  exist,  and  it  is  to  a primary  but  still  indeterminate 
alteration  of  the  nervous  centres  and  of  the  blood,  that  the  symptoms  should  be 
referred. 


88 


ANDRAL’S  MEDICAL  CLINIC. 


SECTION  I. 

TYPHOID  SYMPTOMS,  DEVELOPED  IN  CONSEQUENCE  OP  DIFFERENT  LESIONS 
APPRECIABLE  BY  ANATOMY. 

We  have  selected  the  following  from  among  several  other  analogous  cases, 
to  show  that  diseases,  the  most  different  from  each  other  in  their  seat,  may 
equally  have  as  their  attendants,  or  termination,  symptoms,  always  the  same, 
which  constitute  the  ataxo-adynamic  or  typhoid  state.  Thus  we  shall  see  these 
symptoms  developed  in  consequence  of  an  erysipelas,  of  a phlegmon,  of  different 
diseases  of  the  urinary  passages,  of  pneumonia,  hepatitis,  variola,  measles,  phle- 
bitis, metritis,  etc.  In  these  cases,  we  again  repeat  it,  we  shall  no  longer  find 
this  same  pyrexia,  which  accompanies  follicular  enteritis ; it  will  not  then  be 
the  typhoid  fever  of  MM.  Chomel  and  Louis  ; but  it  will  always  be  the  symp- 
toms of  this  fever  differently  combined. 

Case  34. — Erysipelas  of  the  face  and  trunk — Dark  appearance  of  the  tongue  and  mouth — 

Delirium — Prostration. 

A.  trader  in  umbrellas,  forty-seven  years  of  age,  was  attacked  with  erysipelas 
of  the  face,  when  he  entered  the  Maison  deSante  in  the  January  of  1832.  He 
answered  questions  with  difficulty,  and  raved  from  time  to  time  : the  tongue, 
covered  with  a yellow  coat,  was  at  the  same  time  very  dry  ; pulse  very  frequent 
and  skin  very  hot.  We  were  not  able  to  obtain  any  information  regarding  the 
previous  history  : thirty  or  forty  hours  after  the  patient’s  admission,  desquama- 
tion commenced  to  take  place  in  the  face  ; but  at  the  same  time  a new  erysi- 
pelas appeared  on  the  neck,  and  it  gradually  extended  to  the  chest,  back,  abdo- 
men, and  to  the  commencement  of  the  thighs.  During  ten  days  the  erysipelas 
ceased  not  to  extend.  During  this  time  the  state  of  the  patient  became  more 
and  more  alarming;  complete  delirium  set  in  ; at  first  this  delirium  was  accom- 
panied with  great  excitement ; the  patient  became  very  restless  and  very  noisy; 
he  then  fell  into  a state  of  great  depression,  and  died  comatose.  From  his  ad- 
mission to  his  death  the  tongue  became  drier  and  drier;  at  the  time  the  agita- 
tion and  restlessness  ceased,  it  was  covered,  as  also  the  teeth  and  lips,  with 
black  crusts  ; the  abdomen  was  at  no  time  tympanitic  ; nothing  particular  in 
the  stools;  the  pulse  constantly  remained  very  frequent,  and  became  very  small 
and  weak;  during  the  last  forty  hours  of  life  we  reckoned  it  to  be  146.  Up 
to  the  time  of  death  the  trunk  presented  trac'es  of  erysipelas,  which  had  suc- 
cessively traversed  every  point  of  it. 

Post-mortem.  The  meninges  were  pale,  traversed  with  some  veins  half  filled 
with  blood.  Lungs  engorged  posteriorly  ; healthy  in  every  other  part ; and  the 
arteries  and  veins  were  white  on  their  inner  surface. 

The  mucous  membrane  of  the  stomach  a little  mamillated  towards  the  pylorus, 
presented  towards  its  posterior  surface,  near  the  cardia,  a very  light  red  dotting; 
everywhere  else  it  was  perfectly  white,  and  was  neither  softened  nor  indurated. 
The  duodenum  presented  a greyish  tint.  In  the  jejunum  and  ileum  nothing 
was  observed  but  a number  of  veins  filled  with  blood,  which  passed  beneath  the 
mucous  membrane,  which  was  pale  through  its  entire  extent,  excepting  some 
convolutions,  which  occupied  a descending  position.  There  was  not  a follicle 
apparent  throughout  all  the  small  intestine. 

The  caecum  was  a little  injected  ; the  rest  of  the  large  intestine  was  white. 

The  redness  of  the  skin  of  the  back,  abdomen  and  upper  part  of  the  thighs 
was  gone ; here  and  there  we  observed  on  this  skin  some  large  phlyctenae  filled 
with  reddish  serum. 


DISEASES  OF  THE  ABDOMEN. 


89 


There  can  be  no  doubt  that  the  erysipelas  was,  in  this  case,  the  occasional 
cause,  or,  if  you  will  have  it,  the  starting  point  of  the  ataxo-adynamic  symp- 
toms in  which  the  patient  died.  The  vast  extent  of  skin  attacked  by  inflam- 
mation, was  sufficient,  without  any  other  organ  participating  in  the  disease,  to 
occasion  serious  disturbance  to  the  nervous  system.  Thus,  without  any  altera- 
tion of  the  digestive  passages,  the  tongue  may  become  dry  and  black ; without 
this  alteration,  typhoid  symptoms  maybe  developed.  We  have  been  careful 
to  note  that  the  vessels  were  found  in  the  most  healthy  state,  an  important  cir- 
cumstance, because  it  might  be  supposed  that  the  erysipelas  had  produced  these 
symptoms  only  after  being  complicated  with  phlebitis. 

Case  35. — Phlegmon  terminating  in  gangrene  around  scarifications  made  on  an  infiltrated 
limb  ; adynamic  fever ; tongue  and  teeth  dark-coloured ; fseces  passed  involuntarily  — 
Digestive  tube  healthy — Organic  affection  of  the  heart. 

A man,  fifty-three  years  of  age,  presented  all  the  signs  of  dropsy  from  organic 
affection  of  the  heart,  when  he  was  submitted  to  our  inspection.  A few  days  after 
his  admission,  the  enormous  size  of  the  lower  extremities  induced  M.  Lerminier 
to  scarify  them  ; the  left  extremity  was  soon  emptied,  but  not  so  with  the  right; 
the  thigh  and  leg  of  this  side  soon  presented,  around  the  points  of  the  skin  where 
the  incisions  had  been  made,  a livid  red  colour,  which  soon  became  black ; at 
the  same  time  there  was  considerable  tumefaction  of  the  limb,  general  redness 
of  the  skin  of  the  thigh,  acute  pain  on  the  least  pressure  (emollient  fomenta- 
tions). During  the  three  or  four  first  days  the  general  state  of  the  patient  re- 
mained good  ; but  after  this,  and  according  as  the  phlegmon  went  on,  the  features 
underwent  a rapid  alteration  ; a very  well-marked  expression  of  sinking  was 
observable  on  the  face ; the  mouth  was  filled  with  a viscid,  clammy  mucus,  of 
a dirty  grey  colour;  then  the  tongue  became  brown,  and  dry  as  a bit  of  parch- 
ment ; black  crusts  covered  the  teeth ; the  intellects  became  disturbed  ; the 
patient  ceased  to  answer  questions ; he  was  continually  muttering  some  unin- 
telligible words;  and  he  died  in  this  state  twelve  or  thirteen  days  after  the 
scarification  had  been  made. 

Post-mortem , seventeen  hours  after  death.  • Considerable  serous  engorgement 
of  both  lungs ; a clot  of  some  consistence,  and  of  a yellowish  white  colour,  in  the 
heart,  which  was  aneurismatic,  its  tissue  being  rather  healthy,  and  the  inner  sur- 
face being  pale.  A little  coagulated  blood  in  the  large  arterial  trunks,  which 
presented  no  unusual  colouring,  nor  did  the  veins.  A considerable  quantity  of 
pus  infiltrated  the  cellular  tissue  of  the  right  lower  extremity. 

In  this  case  the  adynamic  symptoms,  the  dryness  of  the  tongue,  the  dirty 
colour  of  the  teeth,  and  the  delirium  came  on  in  consequence  of  the  phlegmon. 
We  have  adynamic  fever  without  the  digestive  tube  presenting  any  appreciable 
lesion  after  death. 

Case  36. — Inflammation  of  one  of  the  kidneys  and  of  the  bladder — Symptoms  of  adynamic 
fever — Tongue  dry  and  black  ; teeth  dark  coloured — Digestive  tube  healthy — Spleen  large 
and  soft. 

A man,  about  sixty  years  old,  was  brought  to  the  Charite  in  the  following 
state;  face  of  a leaden  hue  ; will  not  answer  questions;  constant  muttering; 
lips,  teeth  and  tongue,  covered  with  a dark  coat ; some  petechiae  on  the  abdomen, 
which  was  soft,  and  seems  free  from  pain;  stools  natural;  pulse  small,  very 
frequent ; skin  not  hot ; subsultus  tendinum.  The  two  following  days  the  in- 
dividual remained  nearly  in  the  same  state.  He  died  on  the  third  day. 

Post-mortem.  Brain  healthy ; lungs  slightly  engorged ; heart  empty  ; nothing 
remarkable  observed  in  the  stomach  ; the  right  kidney  of  a deep  red  colour,  and 
its  tissue  very  friable  ; the  calices,  which  were  considerably  dilated,  were  filled 
with  purulent  matter,  which  was  also  found  in  the  ureter  of  this  side ; the 
8* 


90 


ANDRAL’S  MEDICAL  CLINIC. 


bladder,  which  was  contracted  on  itself,  presented  an  unusual  thickness  of  the 
cellular  tissue  interposed  between  the  muscular  and  mucous  coat;  in  some  points 
this  cellular  tissue  had  a schirrous  appearance ; the  entire  mucous  membrane  of 
the  bladder  was  of  a cherry  red  colour ; the  spleen  very  large  and  very  soft. 

In  this  case  we  find  the  digestive  tube  as  healthy  as  in  the  preceding : yet  the 
adynamic  fever  was  here  well  marked.  It  commenced  in  an  affection  of  the 
urinary  passages.  Those  who  have  seen  a certain  number  of  cases  of  chronic 
disease  of  the  urinary  passages,  know  that  it  is  not  uncommon  to  see  life  termi- 
nate in  such  patients  in  the  midst  of  symptoms  of  adynamic  fever;  their  strength 
is  lost,  their  intellects  become  impaired,  their  tongue  dries,  and  they  die. 

Case  37. — Old  attack  of  apoplexy — On  entering  the  hospital,  general  debility  ; soon  after  there 
was  intestinal  hemorrhage ; then  adynamic  symptoms ; tongue  dry  and  black — Death — 
Abscess  in  the  prostate ; another  abscess  in  the  thoracic  muscles — Digestive  tube  presenting 
no  other  lesions  except  a little  redness  in  the  great  cul-de-sac  of  the  stomach — An  old 
hemorrhagic  focus  in  a cerebral  hemisphere. 

A coppersmith,  fifty  years  of  age,  had  an  attack  of  apoplexy.  He  lost  con- 
sciousness for  several  hours  ; when  he  came  to  himself,  his  extremities  on  the 
right  side  were  paralysed  ; the  right  commissure  of  the  lips  was  drawn  down ; 
the  tongue  inclined  to  the  right.  He  was  bled  profusely,  and  covered  with 
sinapisms  and  blisters.  The  paralysis  terminated  at  the  end  of  about  five 
weeks. 

When  he  entered  the  hospital,  he  complained  only  of  general  debility.  We 
observed  him  gradually  to  fall  into  that  state  of  decay  which  the  ancients  desig- 
nated by  the  name  of  cachexy.  His  face  was  very  pale  ; he  was  so  weak  that 
he  could  not  leave  the  bed ; his  movements  were  free,  his  intellect  intact.  At 
the  commencement  of  March  he  voided,  without  pain  or  tenesmus,  a considerable 
quantity  of  blood  by  stool ; he  then  had  a slight  purging,  which  yielded  to  rice 
ptisan.  Fever  became  developed.  He  began  to  feel  pain  at  the  lower  part  of 
the  right  side  of  the  chest. 

March  12th,  tongue  dry,  red  at  the  centre ; thirst ; abdomen  free  from  pain  ; 
pulse  frequent  and  weak;  prostration. 

The  same  state  on  the  two  following  days.  Constipation.  (Decoction  of 
poly  gala.) 

On  the  15th,  tongue  dry  and  black;  some  thirst;  no  stool;  intellects  very 
distinct;  speech  free ; pulse  frequent,  rather  resisting;  continuance  of  the  pain 
of  side. 

On  the  16th,  features  very  much  altered.  Died  the  next  day.  Intellect  per- 
fect to  the  last  moment. 

Post-mortem.  Effusion  of  a considerable  quantity  of  limpid  serum  into  the 
subarachnoid  cellular  tissue.  Ventricles  filled  with  serum.  Externally,  and 
on  the  level  of  the  left  corpus  striatum,  there  existed  an  oblong  cavity,  about 
one  inch  in  length  and  two  in  depth,  and  from  three  to  four  lines  in  width, 
filled  with  a small  quantity  of  a chocolate-coloured  liquid,  lined  by  a thin  smooth 
membrane,  resembling  a serous  membrane.  Cerebellum  softer  than  usual. 
From  the  right  lung,  when  cut  into,  an  enormous  quantity  of  colourless  frothy 
serum  flowed  (oedema)  : there  was  less  of  it  in  the  left.  Considerable  hyper- 
trophy of  the  parietes  of  the  left  ventricle  of  the  heart.  The  inner  surface  of 
the  stomach  was  white  through  its  entire  extent,  except  towards  the  great  cul- 
de-sac,  to  the  extent  of  three  fingers’  breadth  in  every  way.  Here  there  was 
considerable  redness,  which  resided  in  the  mucous  membrane,  which  was  a 
little  softened,  but  still,  however,  capable  of  being  raised  in  the  form  of  mem- 
brane. The  inner  surface  of  the  rest  of  the  intestine,  from  the  duodenum  to  the 
rectum,  was  very  white,  except  in  some  scattered  points,  where  there  was  slight 
sub-mucous  injection. 


DISEASES  OF  THE  ABDOMEN. 


91 


A small  purulent  deposit  was  found  in  the  substance  of  the  thoracic  muscles 
of  the  right  side  ; thence  the  pain  felt  at  this  part. 

We  do  not  think  that  the  state  of  the  digestive  tube  can  here  account  for  the 
symptoms  observed  during  life.  Thus,  again,  there  was  in  this  case  adynamic 
fever,  with  dryness  and  blackness  of  the  tongue,  with  an  origin  elsewhere  than 
in  the  digestive  passages. 

Shall  we  remark  the  hypertrophy  of  the  left  ventricle  of  the  heart,  by  which 
the  resistance  which  the  pulse  presented  up  to  the  last  moments  may  be  ex- 
plained, a resistance  which  seemed  to  disagree  with  the  aggregate  of  the  other 
symptoms  ? Shall  we  again  remark  the  non-cicatrisation  of  the  old  apoplectic 
focus,  though  every  species  of  paralysis  had  for  a long  time  disappeared. 

Case  38. — Red  softening  of  the  liver ; no  other  lesion — Adynamic  fever. 

An  old  man,  nearly  eighty  years  of  age,  entered  the  Pitie  in  the  following 
state  : face  pale,  with  a yellowish  tint  around  the  lips  and  alae  nasi ; a marked 
air  of  stupor  ; such  debility  that  the  patient  cannot  remain  sitting  up  for  a 
few  seconds  ; intellect  very  much  impaired.  The  tongue  protruded  from  the 
mouth  with  difficulty  and  tremor ; a yellow  crust  covers  its  centre,  and  its 
edges,  as  well  as  its  apex,  adhere  to  the  palate  and  teeth  by  a thick  and  viscid 
mucus.  Abdomen  soft  and  free  from  pain  ; stools  but  few.  The  upper  ex- 
tremities were  affected  with  a constant  tremor,  which  at  first  prevents  the  pulse 
from  being  felt ; when  it  is  felt,  it  is  found  to  be  small,  irregular,  and  very 
frequent.  Skin  hot  and  dry  ; movements  of  respiration  separated  by  very  un- 
equal intervals,  and  it  was  observed  to  be  accelerated  and  retarded  alternately  in 
a very  remarkable  manner. 

All  that  we  could  learn  of  his  previous  history  was,  that,  for  the  last  fifteen  days, 
this  old  man  kept  the  bed  ; that  first  he  lost  his  appetite  and  strength,  and  that 
gradually  he  fell  into  the  state  now  described. 

On  the  following  days  the  prostration  increased  more  and  more  ; the  patient 
fell  into  a sort  of  dull  delirium,  which  rendered  him  completely  indifferent  to  all 
external  impressions  ; the  tongue,  teeth,  and  lips,  became  black  ; the  pulse,  with- 
out losing  any  of  its  frequency,  became  thready ; the  skin  became  cold  ; the 
breathing  was  embarrassed  : and  he  died  in  about  twenty  days  after  he  began  to 
keep  his  bed. 

Post-mortem.  Slight  serous  infiltration  of  the  subarachnoid  cellular  tissue  of 
the  convexity  of  the  cerebral  hemispheres.  Meninges  pale  ; about  half  a spoon- 
ful of  limpid  serum  on  each  lateral  ventricle.  Substance  of  the  brain  equally  pale 
as  the  membranes. 

Old  adhesions  of  the  pleurae  costalis  and  pulmonalis  of  the  right  side  ; con- 
siderable rarefaction  of  the  pulmonary  tissue ; engorgement  of  the  two  lungs  at 
their  posterior  part.  Towards  the  summit  of  the  left  lung  several  burst,  or 
dilated  vesicles,  formed,  as  it  were,  large  ampullae,  which  passed  some  lines 
beyond  the  exterior  surface  of  the  lung;  immediately  at  the  summit,  they  sur- 
rounded, to  the  number  of  five  or  six,  a depression  resembling  a cicatrix.  In 
some  points  of  the  two  lungs  the  bronchi  were  found  considerably  dilated.  The 
entire  pulmonary  parenchyma  was  loaded  with  a great  quantity  of  black  colouring 
matter. 

The  cavities  of  the  heart  were  filled  with  coagulated  blood.  Considerable 
ossification  of  one  of  the  aortic  valves.  The  aorta  also  contained  several  plates 
of  bone. 

The  stomach  was  filled  with  a greyish  liquid  which  exhaled  an  acrid  odour. 
Its  mucous  membrane  was  everywhere  pale ; it  was  very  thin  towards  the 
pylorus.  The  villi  of  the  first  curvature  of  the  duodenum  were  coloured  black. 


92 


ANDRAL’S  MEDICAL  CLINIC. 


The  remainder  of  the  small  intestine  was  pale.  No  trace  of  follicles,  whether 
isolated  or  aggregated,  were  discovered  in  it.  The  caecum  was  a little  injected. 

The  liver,  which  was  of  the  ordinary  size,  presented  a uniformly  red  colour, 
but,  what  was  particularly  remarkable  in  it,  was  the  extreme  friability  of  its  tissue, 
which  crumbled  under  the  finger  with  extreme  facility.  A black  and  pitchy  bile 
distended  the  gall-bladder.  Spleen  somewhat  large  and  very  soft. 

This  case  furnishes  matter  for  the  same  reflection  as  the  preceding  ; it  is 
always  typhoid  symptoms  which  are  developed,  without  any  concomitant  lesion 
of  the  digestive  passages.  The  liver  was  here  the  primary  source  whence  the 
symptoms  were  derived ; at  least,  it  was  in  this  organ  only  that  any  alteration 
was  discovered. 

Case  39. — Measles — On  the  second  day  of  the  eruption  violent  delirium,  followed  by  a state 
of  coma — No  appreciable  lesion  in  any  of  the  organs. 

A man,  about  twenty-eight  years  old,  of  strong  make,  entered  the  Pitie  with 
intense  fever,  accompanied  with  a very  violent  cough  and  coryza.  Face  red  ; 
eyes  injected  and  watery  ; tongue  of  a bright  vermilion  colour  ; abdomen  every- 
where soft  and  free  from  pain  ; no  diarrhoea.  Percussion  of  the  chest  gave  but 
negative  information  ; auscultation  detected  a little  mucous  rale  in  different  points. 
This  man  had  a cough  for  the  last  eight  days,  but  only  since  the  last  two  days 
bad  he  any  fever,  and  kept  his  bed.  We  bled  him  to  sixteen  ounces.  Blood  not 
buffed. 

During  the  twenty-four  hours  following  the  patient  remained  in  the  same 
state ; then  his  skin  became  covered  with  an  eruption,  having  all  the  characters 
of  the  best  marked  measles.  At  first  everything  seemed  to  go  on  very  well ; 
then  thirty-six  or  forty  hours  after  the  rubeolar  eruption  first  began  to  appear, 
the  intellect  became  suddenly  disturbed,  and  furious  delirium  soon  set  in. 
We  had  to  put  the  straight  waistcoat  on  him.  He  was  very  much  agitated, 
vociferated  incessantly,  and  railed  at  every  person  who  approached  him.  Frothy 
saliva  constantly  flowed  from  his  mouth  ; he  greedily  swallowed  whatever 
liquids  were  presented  to  him,  and  constantly  importuned  for  something  to  drink  ; 
tongue,  however,  neither  red  nor  dry.  From  time  to  time  the  trunk  was  sud- 
denly raised,  as  if  by  a tetanic  shock.  Continued  subsultus  was  perceived, 
which  prevented  us  from  clearly  ascertaining  the  character  of  the  pulse.  We, 
however,  satisfied  ourselves  that  it  was  very  frequent  and  very  full.  The  erup- 
tion was  still  very  marked  on  the  face  and  chest ; it  had  disappeared  on  the  ex- 
tremities. Forty  leeches  were  applied  to  the  neck,  and,  whilst  the  blood  was 
flowing,  the  lower  extremities  were  covered  with  sinapisms. 

For  three  days  the  same  state  continued  ; a second  application  of  leeches  was 
made  with  as  little  success  as  the  first.  After  this  the  scene  suddenly  changed  ; 
the  violent  excitement  which  the  patient  presented  up  to  this  period  was  all  at 
once  succeeded  by  extreme  prostration  ; profound  coma  soon  came  on,  in  which 
the  patient  died. 

Post-mortem.  On  the  inner  surface  of  the  stomach  we  observed  some  bands 
extending  from  the  cardia  to  the  pylorus  ; the  free  edge  of  some  presented  a 
red  colour,  which  partly  disappeared,  and  became  changed  into  a light  red 
narrow  dotted  streak,  when  these  bands  were  effaced  by  traction.  Some  partial 
injections  observed  in  the  intestines.  Nothing  remarkable  in  any  of  the  other 
organs. 

If  there  be  a case  where  the  alterations  discovered  by  our  senses  do  not 
appear  sufficient  to  explain  the  disease,  and  to  account  for  death,  that  is  unques- 
tionably the  case  now  read.  In  most  of  the  cases  wherein  measles  is  compli- 
cated with  such  serious  symptoms,  we  find  on  the  dead  body  alterations  which 
we  rationally  consider  to  be  the  cause  of  them.  Here  all  the  organs  were  healthy. 
Might  it  not,  however,  be  presumed  that  traces  of  inflammation  would  be  found 


DISEASES  OF  THE  ABDOMEN. 


93 


in  these  nervous  centres  where  the  principal  and  most  important  of  the  func- 
tional disturbances  resided  ? yet  they  were  as  exempt  from  the  lesion  as  the  other 
parts.  What  share  had  the  cutaneous  eruption  in  this  case  ? Certainly  none 
other  than  that  of  exciting  to  action  the  predisposition  to  the  development  of 
nervous  symptoms  in  consequence  of  the  general  disturbance  of  the  system. 
Here,  then,  as  in  a thousand  other  cases,  that  which  appears  to  us  is  but  part  of 
that  which  is,  and  that  which  we  do  not  see  is  precisely  that  which  is  most  im- 
portant. 

Case  40. — Confluent  small-pox — On  the  ninth  day  of  the  eruption  typhoid  symptoms  ; tongue 
black ; petechial  spots  between  the  pustules  : delirium. 

A young  servant  girl,  eighteen  years  old,  went  frequently,  seven  days  before 
she  fell  ill,  into  the  bedroom  of  a person  who  had  small-pox.  She  had  not  been 
vaccinated.  She  entered  the  Pitie  on  the  9th  of  August.  She  first  complained, 
on  the  30th  of  July,  of  general  sickness  and  anorexia.  August  1st,  she  complained 
of  dizziness  of  the  head,  nausea,  and  she  vomited.  On  August  2d,  the  same 
symptoms  ; pains  in  the  region  of  the  kidneys  ; she  kept  her  bed.  August  3d, 
no  more  vomiting  nor  nausea,  but  was  very  weak,  and  did  not  leave  the  bed. 
August  4th,  in  the  morning,  the  face  was  observed  to  be  covered  with  pustules 
(boutons).  The  eruption  went  on  developing  itself  up  to  the  10th  of  August, 
the  time  we  examined  the  patient.  This  was  the  seventh  day,  when  she  was 
covered  with  the  eruption. 

The  entire  skin  was  covered  with  numerous  pustules,  which  constituted  every- 
where a most  confluent  eruption.  These  pustules  were  white,  flattened,  and 
several  of  them  umbilicated.  Between  them  the  skin  was  of  a bright  red  colour 
on  the  face  and  upper  extremities.  She  complained  of  no  other  pain  than  a 
general  smarting  of  the  skin  ; the  pain  in  the  region  of  the  kidneys  was  gone 
since  August  3d.  No  headach.  The  tongue  was  covered  with  a yellowish  coat ; 
it  was  moist,  and  without  redness  on  its  edges  ; some  pustules  were  observed  on 
it.  She  complained  of  a bad  taste  in  the  mouth  ; profuse  salivation  ; the  palatine 
arch  and  velum  palati  were  covered  with  pustules.  Since  the  first  day  of  the 
eruption  the  patient  complained  of  the  throat;  voice  completely  extinct;  she 
had  no  cough;  was  tormented  with  great  thirst;  abdomen  soft  and  free  from 
pain  ; no  stool  for  the  last  three  days  ; passage  of  urine  accompanied  with  great 
smarting  ; pulse  120  ; twenty-eight  respirations  per  minute.  (Infusion  of  mal- 
low flowers  ; mucilaginous  potion  ; diet.) 

On  the  11th,  same  state.  The  skin  of  the  chest  was  intensely  red  in  the  in- 
terval between  the  pustules  ; these  ran  one  into  the  other  on  the  thighs,  forming 
as  it  were  large  ampullae  filled  with  a whitish  liquid.  There  was  profuse  sali- 
vation. 

Up  to  this,  notwithstanding. the  confluence  of  the  eruption,  every  thing  went 
on  very  well.  But,  August  12th,  the  ninth  day  of  the  eruption,  some  delirium 
supervened.  On  this  day  it  still  appeared  only  at  intervals  ; the  patient  appeared 
very  much  debilitated. 

August  13th,  tenth  day  of  the  eruption,  the  delirium  was  constant;  some 
blood  escaped  from  the  opened  pustules,  and  the  face  was  covered  with  a black 
mask.  Breathing  very  much  hurried  ; pulse  140.  The  tongue  was  dry,  and 
covered  with  black  crusts.  The  constipation  still  continued.  The  legs  were 
covered  with  large  violet  spots,  the  only  point  of  the  body  where  intervals  were 
observable  between  the  pustules.  (Continuation  of  diluent  drinks.) 

The  delirium  continued  through  the  day;  the  general  prostration  increased  ; 
yet  in  the  evening,  in  the  midst  of  her  delirium,  the  patient  left  her  bed,  and 
walked  for  a little  about  the  ward.  She  died  on  the  14th,  the  eleventh  day  of 
the  eruption,  at  three  o’clock  in  the  morning. 

Post-mortem , twenty-nine  hours  after  death.  The  tongue,  palatine  arch, 


94 


ANDRAL’S  MEDICAL  CLINIC. 


velum  palati,  and  pharynx,  were  covered  with  a thick  white  coat.  The  mucous 
membrane  beneath  it  was  but  slightly  red  ; inner  surface  of  the  stomach  lined 
by  a yellowish  mucus  ; beneath  it  the  mucous  membrane  was  found  of  a greyish 
white  colour,  and  mamillated  through  nearly  its  entire  extent;  slight  injection 
in  some  points  of  the  great  curvature.  In  no  part  was  it  softened.  The  mucous 
membrane  of  the  duodenum  was  greyish  like  that  of  the  stomach.  Some  parts 
of  the  jejunum  and  ileum  were  of  a livid  red  colour,  the  parts  particularly  in  the 
cavity  of  the  pelvis.  Everywhere  else  the  intestinal  mucous  membrane  was 
white.  In  the  two  last  feet  of  the  ileum  a considerable  number  of  Brunner’s  fol- 
licles were  found  to  be  white,  and  not  at  all  prominent:  in  the  ileum  also  were 
found  five  of  Peyer’s  patches,  forming  no  projection  above  the  level  of  the  mu- 
cous membrane,  which  were  recognisable  only  by  their  black  points,  and  the 
greyer  colour  of  the  intestine  where  they  were  found.  The  mucous  membrane 
of  the  large  intestine  was  everywhere  white  and  of  good  consistence  ; no  follicles 
observable  in  it. 

The  liver,  which  was  of  a uniform  pale  red  colour,  was  rather  friable  ; the  gall- 
bladder contained  a black  thick  bile. 

Both  lungs  were  very  much  engorged  posteriorly,  and  in  some  points,  always 
posteriorly,  they  contained  no  air.  The  mucous  membrane  of  the  larynx  and 
trachea  was  intensely  red.  Some  reddish  serum  was  effused  into  the  pericardium. 
The  heart,  the  tissue  of  which  was  firm,  contained  blood  partly  liquid  and  partly 
coagulated. 

The  slight  alterations  found  in  this  individual  existed  all,  with  the  exception 
of  the  pulmonary  engorgement,  at  the  time  the  small-pox  was  proceeding,  with- 
out being  complicated  with  typhoid  symptoms.  What  was  the  cause  of  these  ? 
We  think  that,  if  we  had  had  the  opportunity  of  examining  the  organs  the  day  be- 
fore that  on  which  the  delirium  set  in,  we  should  have  found  them  in  the  same 
state  as  that  in  which  we  found  them  some  days  later.  What,  then,  was  the  new 
morbid  element  which  intervened  to  stamp,  all  at  once,  so  unfavourable  a cha- 
racter on  the  disease  ? Was  it  merely  a sympathetic  influence  exercised  by  the 
inflamed  skin  on  the  nervous  centres  ? Such  may  be  supposed  ; it  cannot  be 
proved.  Was  it  the  variolic  virus,  which,  after  having  exhausted  its  action  on 
the  skin,  then  directed  its  deleterious  influence  towards  the  two  grand  movers  of 
life,  the  blood  and  nervous  system?  This  is  but  an  hypothesis,  which,  how- 
ever, might  have  more  than  one  analogy  in  its  favour.  Did  the  inflammation 
of  the  skin  produce  a phlebitis  consecutively  ? But,  with  respect  to  this  phle- 
bitis, which  may  happen  in  certain  cases,  we  in  vain  sought  for  it  in  this,  and 
we  also  satisfied  ourselvest  hat  it  had  npt  attacked  the  lymphatic  system.  Lastly, 
were  these  typhoid  symptoms,  so  suddenly  developed,  the  result  of  a purulent 
absorption?  Nothing  here  proves  it;  whilst,  on  the  contrary,  it  is  to  be  pre- 
sumed that  this  absorption  took  place  in  the  following  case:  — 

Case  41. — Confluent  small-pox — On  the  ninth  day,  sudden  sinking  of  the  pustules;  death 

rapidly  supervening. 

A man,  about  thirty  years  of  age,  entered  thePitie  with  confluent  small-pox. 
Up  to  the  ninth  day  of  the  eruption  everything  went  on  very  favourably  ; no 
particular  symptom  presented  itself,  only  the  tongue  was  very  much  swollen. 

On  the  ninth  day,  the  pustules,  which,  the  day  before,  were  fully  suppurated, 
became  suddenly  depressed  ; they  became  emptied  without  being  opened  ; be- 
tween them  the  skin  was  pale  as  the  skin  of  a corpse.  In  the  course  of  the  day 
some  delirium  supervened;  at  night  the  patient  fell  into  a state  of  extreme  pros- 
tration ; the  pulse  was  no  longer  felt.  He  died  in  the  course  of  the  night. 

Post-mortem , thirty  hours  after  death  (6th  of  May,  low  temperature). 

The  examination  of  the  pustules  showed  that  they  were  all  empty,  with  the 
exception  of  two  or  three  situated  on  the  back  of  the  foot ; the  epidermis,  as  it 


DISEASES  OF  THE  ABDOMEN. 


95 


were  puckered  and  wrinkled,  was  in  immediate  contact  with  the  cutis.  In  the 
point  where  the  pustules  were,  this  cutis  was  red  and  a little  swollen ; every- 
where else  it  was  pale. 

The  encephalon  and  its  appendages  presented  no  appreciable  alteration. 

The  inner  surface  of  the  larynx  and  trachea  wras  red  ; the  lungs  healthy, 
slightly  engorged  posteriorly  ; one  of  them  contained  a small  cretaceous  tuber- 
cle at  its  apex  ; the  blood  contained  in  the  heart  and  aorta  was  liquid  ; the  inner 
surface  of  the  aorta  was  red  ; nothing  remarkable  in  the  vascular  apparatus. 

The  pharynx  and  oesophagus  healthy  ; the  inner  surface  of  the  stomach  pre- 
sented, through  its  entire  extent,  as  far  as  the  great  cul-de-sac,  considerable 
mamillation  ; it  was  everywhere  of  a greyish  white,  without  the  least  trace  of 
injection  ; the  small  intestine  generally  pale  ; its  inner  surface  was  studded  with 
a very  great  number  of  Brunner’s  follicles,  which  were  not  more  coloured  than 
the  mucous  membrane  on  which  they  were  raised  ; towards  the  end  of  the  ileum 
we  also  found  several  of  Peyer’s  patches,  which  had  a greyish  tint,  but  which 
did  not  project  above  the  level  of  the  mucous  membrane  ; the  large  intestine  was 
white,  without  any  apparent  follicles  ; the  spleen  was  one-third  larger  than 
ordinary  ; it  was  pale  and  very  soft. 

The  most  prominent  phenomenon  presented  in  this  case  was  the  sudden  de- 
pression of  all  these  pustules,  which  became  all  at  once  emptied  of  the  liquid 
which  filled  them,  without  having  been  previously  torn.  They  did  not  there- 
fore discharge  externally  the  pus  secreted  by  the  cutis  ; it  was  the  latter  which 
reabsorbed  it ; and  must  it  not  then  have  passed  into  the  torrent  of  the  circulation  ? 
We  did  not,  to  be  sure,  find  this  pus  either  in  the  blood  or  elsewhere,  but  the 
reason  is,  because  being  intimately  mingled  with  it,  and  circulating  with  it  mo- 
lecule by  molecule,  it  had  not  yet  had  time  to  separate  from  the  blood,  when 
death  supervened.  Death  struck  the  patient  with  frightful  rapidity  ; the  depres- 
sion of  the  pustules  was  followed  by  the  development  of  terrible  symptoms, 
similar  to  those  of  poisoning  by  some  septic  agent,  and  very  few  hours  elapsed 
between  the  appearance  of  these  symptoms  and  death. 

Case  42.  — Confluent  small-pox — From  the  ninth  to  the  fourteenth  flay  of  the  eruption,  typhoid 

symptoms  became  gradually  developed — Death  on  the  fourteenth  day — Numerous  abscesses 

in  the  lung  and  in  the  cellular  tissue  of  the  deep  region  of  the  neck — Intense  redness  of  the 

mucous  membrane  of  the  digestive  passages. 

A man,  twenty-one  years  of  age,  entered  the  Pitie  18th  of  August.  He  had 
fallen  sick  on  the  14th.  On  the  13th  he  had  gone  to  bed  very  well,  and  slept 
well.  On  the  14th,  when  he  awoke,  he  .felt  an  acute  pain  in  the  kidneys  ; took 
to  his  bed  ; still  ate;  did  not  vomit.  On  the  morning  of  the  16th  the  eruption 
appeared  on  the  face,  and  was  increased  on  the  17th.  On  the  18th,  the  day 
when  we  first  saw  him,  the  eruption  was  general,  confluent,  and  developed,  as 
it  should  be  on  the  third  day.  The  pain  of  the  kidneys  disappeared  since  the 
16th  ; tongue  white  and  moist;  the  palatine  vault  and  velum  palati  were  covered 
with  pustules  ; no  salivation ; some  pain  in  the  throat  since  the  last  few7  hours  ; 
no  thirst ; pulse  64.  (Mucilaginous  drinks  ; diet.) 

August  19th,  the  fourth  day  of  the  eruption,  some  pustules  covered  the  tongue  ; 
its  appearance  not  changed  ; a little  delirium  at  night ; pulse  now  72  ; respira- 
tions IQ  per  minute . 

August  20th,  fifth  day  of  the  eruption,  he  complained  much  of  his  throat ; 
voice  entirely  gone  ; tongue  covered  with  pustules;  only  one  stool ; calmer  at 
night  than  on  the  preceding;  frequency  of  pulse  a little  increased,  being  now 
76;  respirations' 24. 

During  the  four  days  following,  the  intellect  became  disturbed  from  time 
to  time,  and  in  a moment  of  delirium  he  tore  the  pustules  from  his  face. 

August  25th,  tenth  day  of  the  eruption,  the  delirium  became  more  continued  ; 


96 


ANDItAL’S  MEDICAL  CLINIC. 


extremities  exhibited  slight  convulsive  movements ; they,  as  also  the  trunk, 
were  covered  with  pustules  filled  with  pus  ; the  entire  face  covered  with  a black 
mask  ; eyes  easily  opened  ; tongue  dry  as  a bit  of  parchment ; voice  still  entirely 
extinct ; pulse  100. 

Up  to  the  29th  the  delirium  still  continued,  as  also  the  occasional  involuntary 
movements  of  the  limbs  ; the  tongue  now  covered  with  black  crusts.  On  the 
29th  he  died  at  nine  o’clock  at  night,  this  being  the  14th  day  of  the  eruption. 

Post-mortem.  Pia  mater  infiltrated  with  a little  serum  ; a very  small  quan- 
tity of  it  in  the  ventricles.  The  muscles  of  the  neck  were  separated,  and,  as 
it  were,  dissected  one  from  the  other  by  means  of  pus,  which  infiltrated  the 
cellular  tissue  placed  between  their  fasciculi.  Some  pus  was  also  found  effused 
between  the  oesophagus  and  vertebral  column. 

The  stomach  was  dilated  with  gases.  Internally  there  were  observed  bright 
red  dots,  which  were  all  seated  in  the  mucous  membrane,  and  particularly  in 
the  villi  of  this  membrane.  The  inner  surface  of  all  the  small  intestine,  and 
that  of  the  upper  half  of  the  large  intestine,  was  of  an  intensely  red  colour. 
Some  solitary  follicles,  somewhat  numerous,  but  small,  were  found  towards 
the  termination  of  the  ileum.  Spleen  enlarged  in  size,  and  very  soft. 

The  mucous  membrane  of  the  larynx  was  very  red. 

Both  lungs  were  very  much  engorged  posteriorly.  The  lower  lobe  of  the 
left  lung  had  a sieve-like  appearance,  in  consequence  of  a multitude  of  small 
abscesses.  Every  incision  made  by  the  scalpel  fell  on  several  of  the  abscesses, 
so  numerous  were  they.  Some  were  surrounded  by  a perfectly  healthy  paren- 
chyma; around  several  others  the  pulmonary  tissue  was  hepatised.  In  a cer- 
tain number  of  points  there  were  found,  instead  of  abscesses,  small  greyish  masses, 
still  hard,  which  were  evidently  portions  of  the  pulmonary  tissue  infiltrated 
with  pus.  The  upper  lobe  of  the  left  lung  contained  nothing  similar.  In  the 
right  lung  there  was  discovered  only  a single  point  where  the  tissue  of  this 
organ  contained  a little  pus,  which  was  still  found  in  the  state  of  infiltration. 

The  bronchial  ganglions  were  somewhat  enlarged,  but  they  presented  nothing 
remarkable,  except  that  some  of  them  contained  a little  chalky  matter. 

Some  lemon-coloured  serum  was  found  in  the  pericardium. 

In  the  preceding  case  the  serious  symptoms,  which  were  suddenly  developed 
at  the  same  time  that  the  pustules  became  depressed,  were  a reason  for  our  ad- 
mitting purulent  absorption  ; while,  in  this  case,  none  of  the  lesions  found  on 
the  dead  body  could  account  for  these  symptoms. 

Here  the  pustules  remained  full  up  to  the  time  of  death,  except  those  on  the 
face,  which  were  prematurely  torn.  We  still  observe  the  same  symptoms,  but 
more  slowly  developed.  How  shall  we  explain  them  ? There  were  here  two 
species  of  lesions  ; on  the  one  hand,  we  discover  a well-marked  gastro-enterite, 
and  it  alone  may,  no  doubt,  have  had  great  influence  on  the  production  of  the 
typhoid  symptoms ; but,  on  the  other  hand,  we  find  in  the  cellular  tissue  of  the 
neck,  and  particularly  in  the  lung,  numerous  abscesses,  altogether  resembling 
those  found  in  the  same  parts  after  capital  operations,  and  which  have  been 
hitherto  accounted  for  either  by  an  absorption  of  pus,  or  by  a phlebitis.  Here 
this  latter  did  not  exist. 

Wherefore,  we  think  that,  in  this  patient,  the  typhoid  symptoms  were  owing, 
at  one  and  the  same  time,  to  the  absorption  of  pus  and  the  gastro-intestinal 
inflammation. 

We  shall  now  cite  another  case,  in  which  the  same  typhoid  symptoms  still 
appear,  without  there  having  been  any  other  lesion  than  an  intense  inflammation 
of  the  pulmonary  parenchyma. 


DISEASES  OF  THE  ABDOMEN.  97 

Case  43. — Confluent  small-pox—  Typhoid  symptoms  developed  on  the  twelfth  day  of  the 
eruption — Death  on  the  sixteenth  day — Pneumonia. 

A man,  twenty-one  years  of  age,  ran  through  the  different  stages  of  confluent 
small-pox,  without  any  unpleasant  circumstances  up  to  the  twelfth  day  of  the 
eruption.  Then  the  pustules  of  the  face  became  changed  into  yellowish  crusts  ; 
those  of  the  extremities  were  still  full  of  pus.  All  at  once  the  frequency  of 
the  pulse  increased ; the  tongue  became  dry,  the  intellects  disturbed,  and  at  the 
same  time  the  breathing  was  accelerated  ; auscultation  detected  some  crepitous 
rale  towards  the  base  of  the  right  lung  ; there  was  scarcely  any  cough,  no  ex- 
pectoration, and  no  pain  of  side.  He  was  immediately  bled  to  the  amount  of 
sixteen  ounces  ; still  the  symptoms  became  worse;  on  the  one  hand,  without 
the  respiration  appearing  to  be  more  impeded,  the  crepitous  rale  was  replaced 
by  bronchial  respiration  ; and,  on  the  other  hand,  the  dryness  of  the  tongue, 
the  delirium,  stupor,  and  the  prostration,  went  on  increasing.  All  this  continued 
for  fifteen  days,  then  the  patient  died.  From  the  moment  these  new  symptoms 
set  in,  the  eruption  underwent  a remarkable  change.  Some  of  the  pustules 
became  depressed  without  having  been  previously  torn  ; others,  in  much  greater 
number,  were  filled  with  blood. 

Post-mortem.  On  the  inner  surface  of  the  larynx,  between  the  two  anterior 
extremities  of  the  chordae  vocales,  there  was  found  a small  ulcer,  which. seemed 
to  be  the  probable  result  of  the  laceration  of  a pustule  ; slight  redness  of  the 
mucous  membrane  of  this  organ  ; this  redness  more  intense  in  the  trachea  and 
bronchi.  The  inferior  lobe  of  the  right  lung  in  the  state  of  red  hepatisation. 
The  mucous  membrane  of  the  stomach  presented  a multitude  of  intensely  red 
points.  The  snfall  intestine  in  general  but  slightly  injected  ; we  observed  on 
its  lower  fourth  about  fifteen  of  Peyer’s  patches,  of  a greyish  white  colour, 
projecting  a little  above  the  mucous  membrane.  Between  these  patches  were 
found  several  of  Brunner’s  follicles,  df  a white  colour,  and  small  in  size.  Spleen 
very  large  and  very  soft. 

The  pneumonia,  which  complicated  the  variola  here,  was  evidently  the  com- 
mencement of  the  typhoid  symptoms;  they  began  and  increased  along  with  it. 
The  change  which  the  pustules  underwent,  from  the  moment  these  symptoms 
appeared,  we  consider  very  remarkable.  In  this  case,  as  in  all  the  others,  the 
spleen  was  found  large  and  soft.  In  the  midst  of  organic  disturbances  so  varied, 
which  we  observed  to  coincide  with  the  typhoid  state,  this  alteration  of  the 
spleen  is  the  most  constant  lesion.  It  is,  however,  sometimes  wanting. 

Case  44. — Puerperal  metritis,  with  partial  peritonitis — Ataxo-adynamic  symptoms. 

A woman,  twenty-three  years  of  age,  was  safely  delivered  of  her  first  child  in 
the  Maternite.  A few  days  after  her  delivery  she  left  the  house  ; but  she  had 
scarcely  reached  her  own  home  when  she  was  seized  with  a great  shivering, 
which  was  succeeded  by  a burning  heat,  and  at  the  same  time  she  felt  in  the  hy- 
pogastrium  acute  pains,  which  were  increased  by  any  motion  whatever.  Twenty 
leeches  were  immediately  applied  over  the  abdomen  ; still  the  symptoms  did  not 
diminish,  and,  three  days  after  their  invasion,  this  woman  was  admitted  into  the 
Pi  tie. 

The  pain  about  the  hypogastrium  was  then  diminished  ; she  scarcely  felt  it 
when  she  remained  lying  on  her  back  ; in  this  position  she  complained  particu- 
larly of  suffering  very  much  in  the  region  of  the  kidneys.  Gentle  pressure  on 
the  abdomen,  from  the  umbilicus  to  the  pubis,  gave  but  little  pain  ; when  extend- 
ed to  the  iliac  regions,  a more  acute  pain  was  produced.  We  readily  felt  in 
the  hypogastrium  a globular  body,  not  very  moveable,  which  rose  full  three  fin- 
gers’ breadth  above  the  pubis.  The  form  of  this  body,  its  position,  and  its  rela- 
tions, at  once  showed  that  it  was  the  uterus  which,  after  the  accouchement,  had 
9 


98 


ANDRAL’S  MEDICAL  CLINIC. 


attained  an  unusual  size.  There  was  a reddish  while  discharge  at  the  vagina ; 
on  introducing  the  finger  it  was  ascertained  that  the  neck  of  the  uterus  was 
swollen,  softish,  hot,  and  very  painful  to  the  touch  ; its  orifice  was  still  suffi- 
ciently open  for  the  extremity  of  the  index  finger  to  be  able  to  penetrate  into  it  a 
considerable  way.  The  febrile  disturbance  was  intense;  the  pulse,  which  was 
easily  compressed,  was  up  to  132,  and  the  skin  was  hot  and  dry  ; respirations 
twenty-eight  per  minute.  The  tongue,  covered  with  a yellowish  coat,  was  clammy 
to  the  touch.  She  complained  of  great  thirst;  she  had  nausea  the  day  before, 
which  was  now  gone  ; she  had  had  no  stool  since  her  accouchement.  She  also 
felt  general  uneasiness  and  inexpressible  anxiety,  though  her  pains  were  not 
acute.  She  constantly  stated  that  she  had  not  the  command  of  her  ideas  ; that 
she  knew  not  what  was  to  become  of  her  ; she  found  herself  extremely  weak : 
countenance  was  pale,  and  her  features  expressed  great  depression. 

It  seemed  evident  to  us  that  this  woman  had  acute  metritis.  This  affection 
alarmed  us  less  than  the  state  of  the  nervous  system,  and  the  expression  of  her 
countenance.  It  appeared  that  typhoid  symptoms  were  about  to  manifest  them- 
selves ; perhaps  it  was  a case  of  uterine  phlebitis  ; perhaps,  too,  pus  was  already 
circulating  with  the  blood.  We  put  these  questions  to  ourselves,  and,  consider- 
ing the  paleness  of  her  face,  her  sunken  features,  the  well-marked  nervous  anx- 
iety, the  weak  and  compressible  pulse,  we  doubted  the  propriety  of  bloodletting. 
Still  there  was  intense  inflammation  of  the  uterus  ; this  inflammation  was  recent, 
and  it  was  natural  to  think  that,  by  combating  the  local  affection,  and  removing 
it  we  might  give  the  nervous  system  more  chance  of  returning  to  a better  state. 
We  ventured,  therefore,  to  apply  thirty  leeches  over  the  hypogastrium  ; we  ad- 
vised emollient  fomentations  to  be  kept  continually  over  the  abdomen;  and  we 
ordered  a simple  lavement  of  marshmallow  to  relieve  the  constipation  which  ex- 
isted. Internally,  gum  water  was  the  only  drink  prescribed. 

The  leech-bites  bled  very  profusely.  On  the  next  day  the  patient  was  far 
from  being  improved.  The  tongue  was  now  completely  dry  ; the  countenance 
indicated  the  most  profound  stupor  ; it  was  of  a most  remarkable  leaden  hue. 
Her  ideas  were  no  longer  clear;  she  uttered  from  time  to  time  words  without 
meaning,  if  we  asked  her  how  she  found  herself,  she  replied  that  she  was  very 
well  — a fatal  sign  of  a profound’perversion  of  sensibility.  Her  upper  extremities 
were  agitated  by  a constant  tremor;  the  skin  retained  some  heat;  and  the  pulse, 
smaller  than  oil  the  preceding  day,  was  up  to  140.  The  respiration  was  remarka- 
ble for  its  great  irregularity,  being  sometimes  very  much  accelerated,  sometimes 
singularly  slow.  Amidst  these  great  disturbances  of  innervation,  the  state  of  the 
uterus  did  not  seem  to  undergo  any  change ; the  abdomen  might  be  rubbed  with- 
out the  patient  evincing  any  pain. 

Thus  the  typhoid  state,  which  we  doubted  the  day  before,  was  now  strikingly 
marked.  Should  we  here  be  content  with  a merely  expectant  mode  of  treat- 
ment ? We  did  not  think  so.  We  thought  that  the  great  indication  in  this 
case  was  to  recruit  the  strength,  and  we  prescribed  a mixture,  consisting  of 
thirty  drops  of  sulphuric  ether  and  two  drachms  of  dry  extract  of  quinquina ; we 
gave  at  the  same  time  a lavement,  in  which  we  dissolved  twenty-five  grains  of 
sulphate  of  quinine  (the  entire  to  be  given  in  two  demi-lavements)  ; we  also 
ordered  cataplasms  of  linseed  meal,  very  hot,  and  sprinkled  over  with  some 
flour  of  mustard,  to  be  applied  to  the  lower  extremities.  We  ordered,  for 
ordinary  drink,  some  vinous  lemonade. 

This  new  mode  of  treatment  at  first  seemed  to  be  followed  by  some  success  ; 
the  day  after,  in  fact,  the  state  of  sinking  seemed  to  be  diminished,  the  tongue 
was  not  so  dry,  and  the  intellect  seemed  to  be  improved.  But  this  apparent 
amendment  was  but  of  short  duration.  During  the  four  following  days,  though 
the  same  treatment  was  continued,  the  adynamic  stale  progressed  ; the  longue 
and  teeth  were  covered  with  black  crusts;  she  raved  continually.  Totally 


DISEASES  OF  THE  ABDOMEN. 


99 


unconscious  of  everything  passing  around  her,  she  uttered,  from  time  to  time, 
some  unintelligible  words.  She  soon  fell  into  a profound  coma,  in  which  she 
died. 

Post-mortem.  — Nothing  particular  observed  in  the  brain  or  its  appendages. 
The  thoracic  organs  exhibited  nothing  worth  noticing,  except  considerable  en- 
gorgement of  both  lungs  posteriorly.  Some  blood,  partly  liquid,  and  partly 
coagulated,  was  contained  in  the  cavities  of  the  heart.  The  stomach  presented, 
to  the  left  of  its  cardiac  orifice,  over  a space  about  as  large  as  a five  franc  piece, 
a slightly  red  dotted  appearance.  Everywhere  else  the  gastric  mucous  mem- 
brane was  pale,  and  of  natural  consistence.  The  duodenum  was  of  a slate- 
coloured  tint.  Over  the  rest  of  the  intestine  we  found  nothing  but  some  arbori- 
sations scattered  here  and  there,  which  interfered  not  with  the  transparence  of 
the  mucous  membrane,  and  which  were  beneath  it.  The  spleen  was  one-third 
larger  than  natural,  and  very  soft  ; a small  stream  of  water  poured  on  it  was 
sufficient  to  reduce  it  quickly  to  its  fibrous  parenchyma.  The  uterus  went 
aboutthree  fingers’  breadth  above  the  upper  edge  of  the  pubis.  Its  cavity,  which 
was  larger  than  natural,  was  filled  with  purulent  mucus,  white  in  some  points, 
reddish  in  others.  The  membrane  lining  the  parietes  of  this  cavity  was  in- 
tensely red,  and  covered  in  some  places  with  a whitish  layer.  Even  the  tissue 
of  the  uterus,  which  is  usually  so  hard,  was  become  so  friable,  as  to  break  under 
the  pressure  of  the  finger.  This  tissue  was  everywhere  of  a livid  red  colour; 
we  have  nowhere  met  the  least  appearance  of  pus.  The  right  ovary  was  larger, 
redder,  and  more  friable  than  the  left.  It  contained  no  pus.  A sero-purulent 
liquid  was  effused  into  the  cavity  of  the  pelvis,  and  both  sides  of  the  uterus  were 
covered  with  whitish  false  membranes.  No  lesion  of  either  the  arteries,  veins, 
lymphatics,  or  their  glands. 

Here,  again,  is  a case  where  the  typhoid  symptoms  have  an  entirely  different 
commencement  from  that  which  they  had  in  the  preceding  cases  : here  it  is  the 
uterus,  whose  inflammation  carries  into  the  nervous  system  that  very  peculiar 
disturbance  which  produces  the  ataxo-adynamic  state.  The  particular  condition 
in  which  the  woman  was  during  and  after  her  accouchement,  particularly  in  her 
suffering  both  mental  and  bodily  distress,  appears  to  us  eminently  calculated  to 
favour  the  development  of  this  state.  This  case  also  proves  that  the  existence 
of  uterine  phlebitis  is  not  indispensable,  as  some  persons  suppose,  for  the  pro- 
duction of  the  typhoid  state  in  women  attacked  with  puerperal  metritis.  We 
can  even  say  that,  in  a considerable  number  of  cases  of  this  kind  which  we 
observed  at  the  Maternite,  there  were  very  few  in  whom  we  detected  the  ex- 
istence of  phlebitis.  The  following,  however,  is  a case  in  which  the  inflamma- 
tion of  the  veins  had  very  probably  a considerable  share  in  the  production  of 
the  typhoid  symptoms. 

Case  45. — Gangrene  of  the  lower  Up  ; pus  in  the  veins — Abscess  in  the  lungs — Soft  state  of 
the  spleen — Adynamic  symptoms  ; tongue  dry  and  black. 

A woman,  thirty-nine  years  old,  was  brought  to  the  Charite  on  the  evening 
of  the  16th  of  August.  She  presented  a gangrenous  eschar  of  the  lower  lip. 
The  following  is  the  history  of  the  case,  both  as  obtained  from  herself,  as  also 
from  MM.  Piedagnel  and  Merat,  who  attended  her  before  her  admission  into 
the  hospital. 

This  woman,  who  was  in  very  good  health,  and  who  even  suckled  a child  for 
the  last  eighteen  months,  went  the  preceding  Sunday  to  walk  in  the  Champs 
Elysees,  on  which  occasion  she  was  stung  in  the  lower  lip  by  a fly.  She  stated 
this  fact  positively,  but  she  could  not  state  what  sort  of  fly  stung  her.  The  lip 
became  swollen  up  on  Tuesday,  when  M.  Piedagnel  was  called  in.  He  ordered 
fomentations  and  leeches.  He  himself  observed  on  the  lower  lip  a white  trian- 
gular mark,  similar  to  a leech-bite.  The  swelling  increased  : M.  Merat  was 


100 


ANDRAL’S  MEDICAL  CLINIC. 


called  in  on  Friday.  He  recommended  cauterisation  with  caustic  potass,  which 
was  done.  In  the  night  some  delirium  manifested  itself.  At  last  she  was 
removed  to  the  Charite.  There,  the  swelling  not  ceasing  to  gain  ground,  the 
pulse  being  rapid  and  weak,  we  determined  on  another  cauterisation  with  caustic 
potass,  having  first  divided  the  eschar.  (Decoction  of  quinquina.) 

On  the  17th  the  eschar  on  the  lower  lip  was  about  an  inch  broad,  and  was 
raised  with  pus:  an  indolent  swelling  of  the  two  cheeks,  particularly  on  the 
right  side  of  the  chin,  neck,  and  even  the  upper  part  of  the  chest.  A purple-red 
colour,  which  disappeared  on  pressure  ; no  inflammatory  circle  marking  a sepa- 
ration of  the  gangrene,  the  swelling  was  rather  cedematous  than  tense.  Debility, 
anxiety,  pulse  frequent,  and  had  but  little  strength.  More  delirium,  no  headach  ; 
intense  thirst,  no  heat  of  skin  ; abdomen  soft,  and  free  from  pain  ; a little  diar- 
rhoea ; sonorousness  equal  on  both  sides  of  the  chest,  but  a mucous  rale  on  the 
left,  a difficulty  of  expectorating  by  reason  of  the  viscidity  of  the  sputa.  (Thirty 
leeches  to  the  neck,  vinous  lemonade  ; three  semi-lavements,  with  the  decoc- 
tion of  quinquina  and  six  drachms  ( gros ) of  camphor.) 

At  noon  the  blood  flowed  profusely.  Pulse  quicker  and  smaller  than  in  the 
morning;  great  anxiety;  swelling  increased.  In  the  evening  she  refused  to 
drink ; she  fell  into  a state  of  inexpressible  anxiety  ; she  appeared  suffocating*; 
wished  to  throw  herself  out  of  her  bed.  Her  throat  and  mouth  became  filled 
with  a thready  and  tenacious  mucus,  which  we  could  not  gel  rid  of. 

On  the  18th  she  raved  all  the  night ; the  swelling  made  some  progress  towards 
the  chest;  tongue  appeared  dry  and  black.  Pulse  nearly  gone. 

She  died  at  one  o’clock  in  the  afternoon. 

Post-mortem. — The  eschar  being  divided,  it  was  found  to  contain  pus  beneath 
it  and  to  include  nearly  the  entire  substance  of  the  lower  lip.  On  dividing  the 
tissues,  a number  of  small  abscesses  were  found  ; sometimes  the  pus  seemed  to 
flow  from  the  gaping  orifice  of  small  vessels.  On  further  examination,  it  was 
ascertained  that  the  right  facial  vein  was  swollen  beyond  measure,  and  that  in 
some  places  it  contained  pus,  in  others  a reddish  sanies  ; it  was  found  also  to  be 
thickened  and  red  ; and  these  different  alterations,  as  well  of  the  vessels  as  of 
the  contained  liquid,  extended  as  far  as  the  great  angle  of  the  eye,  and  to  the 
right  facial  vein  ; the  same  lesions  were  found  in  the  left  facial  vein,  but  they 
did  not  extend  to  so  great  a height;  on  pressing  the  small  veins  which  opened 
into  these  vessels,  pus  escaped  from  them.  The  right  jugular  vein  was  filled 
with  it;  it  was  thickened  and  red  through  its  entire  extent.  One  of  the  thyroid 
veins  on  the  left  side  was  in  the  same  state.  The  left  jugular  vein  was  in  its 
normal  state.  All  the  large  veins  in  the  upper  part  of  the  body  were  distended 
by  clots  of  blood.  An  abscess,  whose  existence  was  not  at  all  suspected,  was 
found  between  the  pectoralis  major  and  minor  of  the  right  side.  It  did  not  com- 
municate with  the  abscesses  of  the  face. 

The  -brain  was  in  its  normal  state,  except  that  there  was  some  injection 
observable. 

The  left  pleura  was  inflamed  ; a small  purulent  effusion  was  found  in  it ; soft 
pseudo-membrane  of  recent  formation  lined  the  lung,  and  caused  it  to  adhere  to 
the  ribs.  The  left  lung  presented  a great  number  of  abscesses  in  different  states. 
Some  were  found  in  all  its  lobes,  but  principally  at  the  upper  part,  in  the  middle 
of  its  parenchyma,  and  immediately  under  the  pleura.  Some  as  yet  presented 
merely  a sanguineous  mass;  in  others  some  pus  was  mixed  with  the  blood;  in 
others  again  nothing  but  pus  was  observed.  In  other  parts  these  latter  presented 
sometimes  white  pus  of  a good  consistence,  sometimes  reddish,  sanious  pus, 
similar  to  the  liquid  found  in  some  veins.  Old  adhesions  were  observed  on  the 
right  lung.  A very  small  number  of  abscesses  similar  to  the  preceding  were 
found  in  it. 

The  bronchi  were  red  and  filled  with  mucus.  Heart  large  ; its  right  cavities 


DISEASES  OF  THE  ABDOMEN. 


101 


contained  some  fibrinous  clots.  The  spleen  was  partially  softened,  and  reduced 
to  a putrid  substance,  similar  to  the  sanies  of  the  veins.  The  uterus  was  large, 
and  contained  a clot  of  blood.  (This  woman  had  been  menstruating.)  The 
ovaries  were  large  and  flattened.  The  right  presented  a very  well  developed 
yellow  body,  and  in  the  midst  a small  sanguineous  mass.  The  bladder  was  dis- 
tended with  urine. 

This  case  resembles  several  others  of  which  we  meet  numerous  instances  in 
the  surgical  wards  of  our  hospitals.  There  it  is  not  uncommon  to  see  patients 
die  after  more  or  less  severe  operations,  with  these  same  ataxo-adynamic  symp- 
toms, of  which  the  preceding  cases  furnished  us  such  varied  instances  ; and 
further,  we  frequently  see  their  entire  skin  covered  over  with  a yellow  tint.  On 
opening  their  bodies,  the  veins  proceeding  from  the  place  where  the  operation 
took  place  are  found  to  be  inflamed  and  full  of  pus;  this  phlebitis  can  be  traced 
to  a greater  or  less  distance,  and  at  the  same  time  collections  of  pus  are  found 
in  several  parts,  as  the  lungs,  brain,  liver,  and  spleen  ; they  are  also  met  with 
in  the  articulations  and  in  several  points  of  the  cellular  tissue. 

Hitherto  we  have  seen  the  typhoid  phenomena  become  developed  only  in 
consequence  of  acute  diseases,  which  had  in  some  measure  attacked  the  system 
suddenly.  It  may,  however,  also  happen  that  these  phenomena  mark  the  ter- 
mination of  a certain  number  of  chronic  affections,  which  have  gradually  im- 
poverished the  blood  and  exhausted  the  innervation.  The  typhoid  state  which 
then  supervenes  is  but  the  ultimate  expression  of  this  influence  slowly  exercised  ; 
in  this  way  some  persons  die  who  have  been  affected  with  organic  lesions  of  the 
most  varied  character  ; in  this  way  again  several  old  men  die  who  have  remained 
hemiplegic  after  an  attack  of  apoplexy.  We  shall  here  cite  only  one  instance 
of  this  kind,  which  is  remarkable  in  several  other  respects. 


Case  46. — Symptoms  of  adynamic  fever  in  a woman  who,  several  months  before,  had  under- 
gone amputation  of  a cancerous  breast — Cancerous  masses  in  several  organs. 

A woman,  forty-seven  years  of  age,  entered  the  Charite  in  the  following  state. 
Great  prostration  ; dulness  of  intellect,  and  soon  after  complete  delirium  ; coun- 
tenance pale,  and,  as  it  were,  of  a leaden  hue.  Lips  and  teeth  black,  tongue 
very  dry,  and  covered  with  black  crusts  ; a little  tympanitis  of  the  abdomen  ; 
no  diarrhoea.  Pulse  small  and  very  frequent;  tremor  of  the  upper  extremities 
the  moment  the  patient  attempted  to  move  them  ; subsultus  tendinum. 

The  patient  began  to  keep  her  bed  about  fifteen  days  before  entering  the  hos- 
pital, and  she  gradually  reached  the  stale  which  we  have  just  now  described. 
Some  tonics  were  administered  without  any  success.  The  prostration  went  on 
increasing;  a large  eschar  formed  on  the  sacrum,  and  she  died  in  about  two  days 
after  her  admission  into  the  hospital. 

Post-mortem.  — In  the  place  of  the  amputated  breast  there  was  found  a 
healthy  cicatrix,  beneath  which  no  accidental  production  was  observed.  The 
other  breast  was  not  diseased.  On  the  side  of  the  amputated  breast,  there  were 
found  in  the  axilla  some  lymphatic  ganglions  enlarged  in  size,  and  of  a lardaceous 
tissue. 

This  same  lardaceous  tissue  was  found  in  the  following  parts  : — 1st.  In 
the  liver,  which  was  as  it  were  infarcted  with  a great  number  of  white,  hard 
masses,  which  had  all  the  characters  of  encephaloid  matter  still  in  the  crude 
state. 

2dly.  In  the  spleen,  where  we  discovered  masses  similar  to  those  occupying 
the  liver. 

3dly.  In  the  right  kidney,  one  of  the  cones  of  the  tubular  substance  of 
which  was  entirely  changed  into  encephaloid  matter.  From  this  cone,  thus 
changed  in  structure,  prolongations  were  observed  to  proceed  of  an  accidental 
9* 


102 


ANDRAL’S  MEDICAL  CLINIC. 


production,  which  extended  as  it  were  by  radiation  to  different  points  of  the  corti- 
cal substance. 

4thly.  In  the  uterus,  the  body  of  which  contained  three  large  cancerous 
masses. 

5thly.  In  the  lymphatic  ganglions  along  the  vertebrae,  in  those  particularly 
around  the  receptaculum  chyli. 

6thly.  In  the  right  lung,  through  the  substance  of  which  there  were  scattered 
from  ten  to  twelve  small  white  masses,  similar  to  those  of  the  liver,  spleen,  &c. 
These  masses  appeared  to  be  limited  to  certain  lobules.  But  further,  there 
was  found  in  the  lung  another  and  a more  uncommon  lesion  ; namely, ‘numer- 
ous lymphatic  vessels  distended  with  a whitish  matter,  which  was  observed 
over  the  external  surface  of  the  right  lung,  dipped  into  its  substance,  and  termi- 
nated in  the  diseased  lobules,  where  it  was  lost.  The  other  lung  presented  no- 
thing similar. 

7thly.  The  thoracic  duct  was  filled  with  a turbid,  whitish  matter,  in  which 
were  suspended  some  shreds  of  the  same  colour. 

Nothing  particular  was  observed  in  the  other  organs,  except  that  the  mucous 
membrane  of  the  stomach  presented  in  its  right  half  a slight  slate-coloured  tint, 
and  some  veins  filled  with  blood  passed  beneath  this  membrane  towards  the  great 
cul-de-sac. 

Here  is  a very  remarkable  case,  wherein  we  find  no  lesion  of  recent  formation, 
which  can  be  considered  as  the  origin  and  cause  of  the  ty.phoid  phenomena.  We 
can  no  longer  explain  them  but  by  admitting  that  the  general  alteration  of  nu- 
trition had  gradually  deteriorated  the  hematosis  and  innervation  to  such  a degree, 
that  the-  slightest  shock  given  to  the  system  was  sufficient  to  produce  the  typhoid 
state. 

When,  in  cases  more  or  less  analogous,  we  observe  adynamic  symptoms  to 
supervene,  it  is  much  more  usual  to  meet  with  some  intercurrent  inflammation, 
which  has  produced  them,  by  reason  of  the  unfavourable  conditions  in  which 
the  system  happened  to  be  at  the  time  : the  conditions  are  the  predisposing 
cause,  whilst  the  inflammation  is  but  the  occasional  cause.. 


SECTION  XL 

TYPHOID  SYMPTOMS,  WITHOUT  LESIONS  APPRECIABLE  BY  ANATOMY. 

The  case  which  terminates  the  preceding  paragraph  has  already  furnished  to  us 
an  instance  in  which,  among  the  numerous  alterations  found  in  the  dead  body, 
none  could  be  considered  as  the  immediate  cause  of  the  symptoms  of  adynamic 
fever  which  terminated  the  patient’s  life.  In  order  to  account  for  them,  we  were 
obliged  to  suppose  a particular  modification  of  the  innervation,  which  the  necropsy 
was  unable  to  point  out  to  us.  It  is  cases  of  this  kind,  in  which,  however,  there 
is  no  longer  even  a previous  chronic  affection,  as  in  the  forty-fifth  case,  that 
we  have  detailed  in  this  paragraph.  The  study  of  similar  cases,  however,  un- 
common in  other  respects,,  appears  to  us  to  be  highly  interesting,  inasmuch  as 
it  accustoms  us  to  see  that  the  scalpel,  alone  is  far  from  giving  us  the  key  to  all 
the  problems  of  our  science,. 

Case  47. — Symptoms  of  gastric  disturbance  at  the  commencement;  profuse  evacuations  up 
and  down  after  the  administration  of  two  grains  of  tartar  emetic — Sudden  appearance  of 
ataxo-adynamic  symptoms,  and  death  after  some  hours — Very  rapid  putrefaction  after  death — 
No  lesion. 

A medical  student  had  for  several  years  been  subject  to  great  and  unremitting 
mental  suffering,  and  considerable  privations.  When  he  attained  his  twenty- 


DISEASES  OF  THE  ABDOMEN. 


103 


eight  year  his  situation  became  improved.  Whilst  he  was  unfortunate,  he  con- 
sulted me  several  times  fora  chronic  affection  of  the  stomach,  which  had  dis- 
appeared from  the  time  he  began  to  be  more  happy  in  his  circumstances.  To- 
wards the  latter  end  of  May,  1831,  he  consulted  me  again,  not  on  account  of  his 
health,  which  he  assured  me  was  excellent,  butconcerning  bis  course  of  life.  On 
the  5th  of  June  he  begged  of  me  to  pay  him  a visit,  in  consequence  of  being  taken 
ill.  He  then  gave  me  the  following  account.  June  2d,  he  began  to  feel  some  pain 
of  head.  On  the  next  day  he  felt  ill  all  over  him,  and  his  appetite  was  lost. 
He  remained  in  the  same  state  on  the  4th  ; he  thought  he  had  some  fever.  On 
the  5th  I found  him  in  the  following  state  : 

Slight  headach,  principally  seated  in  the  frontal  region,  yellow  tint  in  the  face. 
General  debility.  Feeling  oflassitude.  Bitter  taste  in  the  mouth  ; tongue  broad, 
covered  with  a yellow  coat,  without  any  redness  of  its  edges  and  apex  ; nausea, 
and  from  time  to  time  he  threw  up  whatever  liquids  he  had  swallowed  ; no 
thirst ; complete  loss  of  appetite  ; abdomen  in  every  part  soft  and  free  from  pain  ; 
constipation.  , Skin  not  hot  and  pulse  not  frequent  (being  70).  These  symptoms 
seemed  to  require  an  emetic  ; the  patient  took  immediately  two  grains  of  tartar 
emetic  in  two  half-glasses  of  water.  It  was  then  four  o’clock  in  the  afternoon. 
In  the  night  he  had  profuse  vomiting,  and  a great  many  stools.  All  the  morn- 
ing of  the  sixth  he  was  very  much  depressed.  I visited  him  again  at  four  in  the 
evening;  he  was  then  in  a state  of  indescribable  anxiety.  His  state  of  anguish 
was  such  that  he  could  not  answer  questions  without  considerable  difficulty. 
However,  the  only  local  suffering  he  complained  of  was  an  acute  pain  in  the  two 
arms,  which  pain  was  aggravated  when  his  limbs  were  moved.  The  tongue 
had  retained  its  moisture ; the  abdomen  was  every  where  free  from  pain  and 
soft,  the  skin  was  not  hot,  pulse  frequent  and  small.  The  patient  expressed  to 
me  a desire  to  be  removed  to  the  Fine,  into  one  of  my  wards  ; he  was  instantly 
brought,  and  he  scarcely  arrived  there  when  he  was  bled.  I know  not  what 
happened  to  him  during  the  night,  but  on  the  7th  of  June,  at  seven  in  the  morn- 
ing, he  was  in  the  last  struggle.  His  features  were  awfully  changed  ; intellect 
completely  gone  ; extremities  cold,  and  pulse  thready.  Still  further,  an  extra- 
ordinary phenomenon  struck  us  ; namely,  the  black  colour  of  the  scrotum  and 
penis,  which  was  at  the  same  time  swollen  ; one  would  have  said  that  these  parts 
were  attacked  with  gangrene.  An  hour  after,  the  skin  of  the  chest,  beneath  the 
two  clavicles,  had  also  a deep  violet  tint,  tending  to  black,  and  the  same  colour 
began  to  spread  over  different  parts  of  the  extremities.  He  died  at  nineo’clock 
in  the  morning. 

Post-mortem.  Twenty-five  hours  after  death.  (During  all  the  time  from 
the  moment  of  his  death  to  the  autopsy  the  temperature  was  lower  than  it  usu- 
ally is  in  the  month  of  June  ; and  other  bodies,  examined  on  the  same  day,  and 
even  a longer  time  after  death,  presented  no  trace  of  putrefaction.) 

The  meninges  and  surface  of  the  cerebral  convolutions  presented  a reddish 
tint,  similar  to  that  which  is  found  in  these  parts  on  bodies  which  have  been  for 
several  days  in  a state  of  putrefaction.  A little  reddish  serum  was  found  in  the 
ventricles;  all  the  cerebral  pulp  was  soft. 

The  lungs,  which  were  gorged  with  blood,  were  greenish  on  their  surface. 

The  heart  contained  in  its  different  cavities  some  liquid  blood,  in  which  was 
observed  a great  number  of  liquid  air-bubbles.  Its  tissue  was  soft  and  reddish, 
and  on  its  inner  surface  it  presented  a brown  red  colour.  The  arteries  and  veins, 
in  which  a liquid  and  frothy  blood  was  also  found,  presented  a red  tinge  on 
their  inner  surface. 

The  mucous  membrane  of  the  stomach  was  separated  from  the  subjacent  tis- 
sues by  a considerable  quantity  of  gas.  Everywhere  this  membrane  was  white 
and  of  some  consistence.  Very  close  to  the  cardia,  to  the  right  of  this  orifice, 
there  appeared  from  five  to  six  blackish  spots,  which  consisted  of  blood  which 


104 


ANDltAL’S  MEDICAL  CLINIC. 


infiltrated  the  very  tissue  of  the  mucous  membrane  : they  were  real  petechiae. 
The  inner  surface  of  the  duodenum,  jejunum,  and  ileum,  and  of  all  the  large  in- 
testine, were  everywhere  remarkably  pale.  There  were  neither  follicles,  nor 
Peyer’s  patches,  enlarged.  The  spleen  was  enlarged,  and  very  soft.  The 
tissue  of  the  liver  was  very  friable  and  pale.  The  gall-bladder  contained  a 
little  greenish  bile.  The  kidneys  were  reddish,  the  bladder  was  distended  by 
a great  quantity  of  urine,  and  its  inner  surface  was  white.  The  black  colour 
of  the  skin  of  the  scrotum,  of  the  penis,  thorax,  and  other  points,  was  owing  to 
a sanguineous  infiltration  of  the  sub-cutaneous  cellular  tissue. 

As  a first  fact,  it  should  be  laid  down  that,  with  the  exception  of  the  ecchy- 
moses  and  petechiae,  all  the  other  alterations  found  on  the  dead  body  were  evi- 
dently a result  of  putrefaction.  But  a very  remarkable  circumstance  in  this 
case  is,  the  rapidity  with  which  the  decomposition  of  the  parts  began  to  take 
place.  A longer  time,  or  a higher  temperature,  is  ordinarily  required,  in  order 
that  we  may  find  all  the  cadaveric  lesions  observed  in  this  case,  as  liquefaction 
of  the  blood,  the  frothy  state  of  this  liquid,  red  colouring  of  several  tissues, 
softening  of  several  others,  emphysema  of  the  stomach,  &c.  Suppose  an 
individual  poisoned  by  any  septic  substance  ; this  is  the  precise  state  in  which 
his  body  will  be  found,  in  this  case  also  there  will  have  been,  before  death, 
transudation  of  the  blood  through  its  vessels,  and  here  the  same  phenomenon 
took  place  ; several  portions  of  the  subcutaneous  cellular  tissue  were  filled  with 
blood  before  death  came  on.  Had  the  patient’s  life  been  prolonged  for  some 
hours,  if  we  may  judge  from  the  rapidity  with  which  the  blood  was  effused 
under  different  points  of  the  skin,  it  is  very  probable  that  all  this  membrane 
would  have  presented  but  one  extensive  ecchymosis  ; probably  too  some  hours 
later  the  mucous  membrane  would  in  their  turn  have  allowed  the  blood  to 
pass  through  them,  and  the  black  vomit  would  have  taken  place.  Were  there 
not  some  petechiae  already  in  the  stomach  ? Thus,  in  this  extraordinary  disease, 
what  we  principally  observe  were  phenomena  similar  to  those  which  present 
themselves  when  a miasm  or  septic  poison  has  vitiated  the  blood. 

We  think  then  that  there  existed  in  this  case  an  alteration  of  the  blood.  Was 
it  primary  ? Was  it  the  origin  and  cause  of  the  other  phenomena?  — or,  was 
itself  the  result  of  the  vitiated  state  of  the  innervation  ? — a question  which  can- 
not be  solved  in  the  present  state  of  science.  Remark,  also,  how  insidious  the 
onset  of  the  disease  was.  Simple  gastric  disturbance  opened  the  scene,  and  in 
some  hours  if  became  changed  by  a group  of  symptoms  approaching  those  of 
the  most  malignant  typhus.  No  doubt  the  life  of  mental  distress  and  bodily 
privation,  from  which  this  young  man  had  but  just  emerged,  had  left  in  his 
entire  organism  a predisposition  to  such  consequences. 

A case  which  bears  many  points  of  resemblance  to  that  now  detailed,  was 
published  some  years  since,  by  Dr.  Gauthier,  of  Clanbry  :*  neither  in  this  case, 
nor  in  our  own,  was  it  to  the  circumscribed  inflammation  of  a solid  that  the 
origin  and  onset  of  the  disease  can  be  referred,  but  to  an  unknown  morbid  state 
either  of  the  nervous  system  or  of  the  blood. 

The  subject  of  Mr.  Gauthier’s  case  was  nineteen  years  of  age.  After  most 
painful  mental  exertion  and  prolonged  watching,  he  had  a swooning  fit.  Two 
hours  after  this  attack,  which  left  him  weak,  and,  as  it  were,  exhausted,  he  was 
seized  with  an  intense  fever  ; he  felt  extreme  anxiety  ; his  limbs  were  painful ; 
he  complained  of  his  throat ; the  general  sensibility  was  very  much  exalted,  the 
tongue  was  red,  as  well  as  all  the  mucous  membrane  of  the  mouth  and  pharynx  ; 
the  respiration  was  unequal  ; some  delirium  supervened.  Two  days  passed  in 
this  way;  then  the  disturbance  of  the  innervation  commenced  ; the  pulsations 
of  the  heart  and  arteries  became  irregular  and  weak,  the  breathing  extremely 


* Archives  tie  Medicine,  tom.  xxiii.,  p.  232. 


DISEASES  OF  THE  ABDOMEN. 


105 


laborious  ; the  muscular  strength  was  diminished  ; the  sensibility  was  abolished  ; 
the  intellect  was  very  much  impaired  ; the  extremities  became  cold,  and  a 
clammy  sweat  was  the  precursor  of  death,  which  came  on  eighty-five  hours 
after  the  occurrence  of  swoon.  He  had  been  bled  repeatedly. 

In  order  to  account  for  all  these  symptoms  so  extremely  ataxic , and  the  ag- 
gregate of  which  at  another  period  would  have  been  called  malignant  fever , 
what  was  found  at  the  -post-mortem  examination  ? A considerable  and  general 
engorgement  of  the  venous  system,  everywhere  liquid  and  purple  blood,  effused 
in  several  points  into  the  cellular  tissue  under  the  form  of  ecchvmosis ; and 
further,  an  extraordinary  softening  of  most  of  the  organs,  of  the  brain,  heart, 
lungs,  liver,  spleen,  kidneys,  even  of  the  very  muscles,  which,  in  every  part, 
could  be  readily  torn,  and  presented  at  the  same  time  a pale  colour. 

The  two  facts  now  cited  appear  to  us  highly  important,  and  we  direct  all  the 
attention  of  observers  to  them. 

Here  now  is  another  case  in  which  the  functional  disturbances  seem  more 
especially  directed  to  the  nervous  centres.  The  blood  no  longer  appears  to 
be  the  cause  of  them.  The  disease  in  the  case  now  about  to  be  detailed,  would 
have  been  called  ataxic  fever  by  Pinel ; meningitis,  or  meningo-cephalitis  by 
others.  The  information  afforded  by  the  necropsy  was  here  again  completely 
negative. 

Case  48. — Febrile  delirium  ; convulsive  movements — After  the  application  of  leeches  sudden 
sinking;  which  was  followed  by  death— No  appreciable  lesion. 

A boy,  seventeen  years  of  age,  of  a strong  constitution,  began  to  feel,  on  the 
22d  of  January,  an  intense  headach,  general  illness,  great  depression  : he  con- 
tinued, however,  to  work,  and  to  eat.  On  the  27th  of  January,  in  order  to 
relieve  his  headach,  he  drank  some  brandy.  This  aggravated  his  suffering.  On 
the  28th  he  entered  the  Maisoti  de  Sante,  and  presented  the  following  state  : — 

Face  very  much  injected,  as  also  the  conjunctivae.  Ideas  rather  confused,  and 
he  answered  the  questions  put  to  him  very  indistinctly.  Pulse  120,  skin  burn- 
ing hot.  Tongue  moist,  and  not  red,  abdomen  soft  and  free  from  pain,  no 
diarrhoea.  We  directed  twenty  leeches  to  the  anus.  According  to  our  opinion, 
this  patient  had  an  inflammatory  fever  with  predominance  of  cerebral  excite- 
ment. 

The  next  day,  we  found  the  patient  perfectly  delirious,  and  from  time  to  time 
the  face  and  extremities  were  agitated  by  convulsive  movements.  The  fever 
still  continued  ; appearance  of  the  tongue  natural.  He  was  bled  to  twelve 
ounces. 

In  the  morning  of  the  30th,  his  state  was  the  same.  We  ordered  twelve 
leeches  behind  each  ear.  A little  time  after  our  visit,  and  before  the  leeches 
were  applied  a strong  convulsive  fit  came  on,  in  which  all  the  body  participated, 
and  which  was  followed  by  great  prostration.  At  noon,  however,  the  leeches 
were  applied  ; their  bites  continued  to  bleed  till  two  o’clock.  The  patient  was 
then  weak  and  covered  with  a cold  sweat ; the  blood  was  stopped  ; but  the 
prostration  increased,  the  pulse  ceased  to  beat,  and  the  patient  died  at  seven 
o’clock  in  the  evening. 

No  organic  lesion  detected  in  any  part  of  the  body. 

Here  is  a well-marked  instance  of  continued  fever  with  the  phenomena  con- 
centrated towards  the  nervous  system,  without  anatomy  being  able  to  discover 
any  lesion  which  could  account  for  them.  Can  it  be  said  that  the  disease  existed 
nowhere,  or,  if  some  will  have  it  so,  that  it  existed  everywhere?  We  shall 
not  reason  so  ; we  shall  place  the  seat  of  the  evil  where  the  symptoms  pointed 
it  out,  namely,  in  the  brain  ; but  this  fact  is  to  be  added  to  several  others,  which 
prove  the  insufficiency  of  our  present  means  of  investigation  to  discover  in  the 
dead  brain  the  traces  of  the  disease  seated  in  it. 


10G 


ANDRAL’S  MEDICAL  CLINIC. 


In  the  case  now  before  us  was  the  disease  an  inflammation?  Should  it  be 
combated  by  bleeding?  One  would  be  tempted  to  doubt  it,  seeing  the  little 
success  attending  the  bleeding  employed,  and  particularly  when  one  considers 
the  very  unfavourable  results  which  followed  the  last  application  of  leeches. 
Was  it  a case  for  the  administration  of  opium  ? We  do  not  think  so;  we  did 
not  here  discover  the  characters  of  that  peculiar  delirium  which  yields  to  nar- 
cotics, and  of  which  we  shall  speak  in  a subsequent  part  of  this  work.  It  is  in 
cases  of  this  kind,  where  the  nervous  disturbance  seems  to  be  the  entire  disease, 
that  cold  effusions,  employed  according  to  the  method  of  Dr.  Recamier,  might 
be  tried  with  some  chances  of  success. 

The  different  cases  detailed  in  this  paragraph  appertained  to  diseases  which 
had  a rapid  course,  a very  short  duration,  and  in  which  the  adynamic  or  ataxic 
symptoms  developed  themselves  from  the  commencement.  These  diseases  have 
not  the  aspect  of  those  designated  by  MM.  Chomel  and  Louis  by  the  name  of 
typhoid  fevers.  Hitherto,  in  all  the  cases  connected  with  this  latter  affection 
which  we  have  detailed,  we  found  some  alteration,  the  intensity  of  which  was 
in  general  proportioned,  with  some  exceptions,  to  the  severity  of  the  symptoms 
during  life.  . Are  there,  however,  cases  where  typhoid  fever,  including  under 
this  designation  only  the  affection  so  called  by  MM.  Chomel  and  Louis,  leaves 
on  the  dead  body  no  lesion  to  which  both  the  symptoms  and  death  can  be 
rationally  attributed  ? 


CHAPTER  II. 

CONTINUED  FEVERS  TERMINATING  IN  A RETURN  TO  HEALTH. 

The  object  of  the  preceding  cases  and  observations  was  to  determine,  by  the 
study  of  the  lesions  found  on  the  dead  body,  the  seat  and  nature  of  the  diseases 
described  by  nosographists  under  the  names  of  inflammatory,  bilious,  nervous, 
adynamic,  and  ataxic  fevers. 

The  following  cases  will  present  to  us  these  same  diseases,  from  their  mildest 
to  their  most  intense  forms,  terminating  with  more  or  less  certainty  in  a return 
to  health,  under  different  modes  of  treatment.  But,  in  order  to  judge  of  the 
efficacy  of  these  modes,  it  will  be  necessary  that  we  not  only  direct  our  attention 
to  these  cases  of  recovery,  for  there  are  some  patients  who  recover  or  die, 
whatever  treatment  may  be  employed;  it  will  also  be  necessary  that  we  re- 
trace our  steps,  and  that  with  respect  to  therapeutics  we  compare  those  cases 
which  terminated  in  death  with  those  where  recovery  took  place. 

On  studying  the  effects  of  these  different  methods  of  treatment,  we  shall  find 
more  than  once,  that  their  success  cannot  be  always  explained  solely  by  our 
ideas  of  pathological  anatomy,  and  that  the  lesions  found  on  the  dead  body  do 
not  in  all  cases  furnish  the  only  therapeutic  indication  ; there  are  other  indica- 
tions to  be  sought,  both  in  the  nature  of  the  causes  which  have  produced  the 
disease,  and  particularly  in  the  state  of  innervation,  which  sometimes  has  existed 
previously  to  the  disease,  the  form  and  intensity  of  which  is  determined  by  this 
state,  and  which  is  sometimes  produced  by  the  disease  itself.  We  shall  thus 
conceive  why,  in  practice,  whilst  we  know  that  in  most  of  what  are  called 
essential  fevers  there  is  gastro-intestinal  irritation,  it  will  not  be  unreasonable  in 
some  cases  to  pay  but  secondary  attention  to  this  irritation,  and  to  exert  our 
principal  efforts  to  produce  some  modification  in  the  innervation  by  the  em- 
ployment of  tonic  and  antispasmodic  substances,  which  no  doubt  have  been 
often  very  much  abused,  but  whose  use  we  are  not  yet  warranted  in  entirely 
proscribing. 


DISEASES  OF  THE  ABDOMEN. 


107 


The  following  cases  will  present  to  us  those  diseases  known  by  the  name  of 
fevers , treated,  first,  by  the  mere  expectant  method  ; secondly,  by  evacuants  ; 
thirdly,  by  antiphlogistics  properly  so  called  (bleeding  and  revulsives)  ; fourthly 
by  tonics. 


ARTICLE  I. 

TREATMENT  BY  DIET  AND  SIMPLE  DILUENTS. 

Case  49. — Recent  arrival  in  Paris — Diarrhoea  at  the  commencement;  fever;  return  of  the 
transpiration  which  had  been  suppressed  ; cure — Eleven  days’  duration. 

A servant  girl,  twenty-one  years  of  age,  of  a strong  constitution,  three  months 
residing  in  Paris,  felt  general  illness  on  the  8th  of  October  without  any  known 
cause;  she  lost  all  appetite,  and  was  attacked  with  severe  purging.  For  the 
eight  days  following,  the  diarrhoea  and  fever  continued.  The  patient  eat  almost 
as  much  as  in  health.  She  entered  the  Charite  on  the  16th  of  October,  at  which 
time  she  complained  of  headach.  The  face  was  red,  the  tongue  white,  bad 
taste  in  the  mouth,  burning  thirst,  pain  in  the  umbilical  region.  She  had  had 
twelve  very  liquid  stools  during  the  last  twenty-four  hours.  The  pulse  was 
scarcely  frequent,  skin  not  very  hot.  In  the  state  of  health  the  axillae  were  the 
seat  of  very  profuse  perspiration,  which  had  now  stopped.  We  prescribed  two 
demi-lavements  of  marsh-mallow  and  poppy,  barley  ptisan  with  mucilage,  strict 
diet.  In  the  course  of  the  day  the  patient  went  but  four  or  five  times  to  stool. 
In  the  evening  she  had  considerable  fever.  In  the  night  she  was  tormented  with 
frequent  nausea.  On  the  morning  of  the  17th  she  was  in  the  same  state  as  on 
the  day  before,  the  purging  was  lessened  ; no  febrile  accession  in  the  evening, 
and  she  slept  rather  well  during  the  night.  On  the  18th  the  same  prescription. 
She  had  but  one  stool  during  the  day.  19th  she  found  herself  very  well,  and 
had  some  appetite.  The  axillary  transpiration  was  re-established  during  the 
night.  She  left  the  hospital  on  the  21st. 

The  cure  of  this  patient  was  prompt  and  easy.  She  was  scarcely  relieved 
from  the  purging  and  fever,  when  she  completely  recovered  her  health  and 
strength.  She  had  not,  in  some  degree,  a stale  of  convalescence.  Would  she 
have  recovered  so  rapidly,  if  she  had  been  exhausted  by  bloodletting.  We  may 
also  remark  in  this  woman  the  suppression  of  an  habitual  partial  transpiration, 
which  was  re-established  on  the  return  of  health.  If  the  morbid  symptoms  had 
persisted,  it  would  have  been  judicious  to  endeavour  to  restore  the  axillary 
transpiration  by  means  of  frictions,  warm  fomentations,  the  application  of  irri- 
tants to  the  part,  &c. 

Case  SO.—  Excessive  hard  labour  and  bad  diet — Diarrhoea  at  the  commencement — Tongue  dry 
at  intervals — Disease  of  three  weeks’  duration. 

A tailor,  twenty  years  of  age,  had  spent  several  nights  at  work,  and  was  but 
badly  fed.  His  disease  commenced  by  profuse  diarrhoea.  When  he  entered 
the  Charite  his  countenance  was  pale  and  harassed  ; bronchial  irritation  was 
added  to  that  of  the  intestines.  'The  purging  stopped  several  times  for  one  or 
two  days,  and  then  it  reappeared  ; the  tongue  became  dry  and  red  from  time  to 
time.  These  alternations  of  better  and  worse  were  observable  on  the  patient 
for  about  three  weeks.  He  took  nothing  but  barley  ptisan,  some  juleps  at 
night,  and  some  demulcent  lavements. 

In  this  case  the  symptoms  announce  considerable  irritation  in  the  digestive 
tube.  Should  we  have  endeavoured  to  abridge  its  duration  by  the  employment 
of  bloodletting  ? We  think  that  its  employment  would  not  have  been  unattended 


108 


ANDRAL’S  MEDICAL  CLINIC. 


with  injury  in  the  case  of  a person  whose  digestive  tube  was  irritated  only  in 
consequence  of  certain  influences,*  which  had  placed  the  nervous  system  and 
the  blood  in  morbid  conditions,  calculated  to  effect  a change  in  the  entire  sys- 
tem before  the  gastro-intestinal  irritation  appeared.  Often  have  we  seen,  in 
such  cases,  that  the  bleeding  did  not  remove  the  local  affection,  and,  more- 
over, that  it  was  immediately  followed  by  a state  of  prostration,  which  increased 
according  as  the  bleedings  were  repeated  ; so  that,  under  such  circumstances, 
the  therapeutic  indications  should  be  deduced  less  from  the  local  lesion,  which 
gives  its  name  to  the  disease,  than  from  the  state  of  the  patient  before  this  lesion 
was  developed. 

Case  51 . — Shivering  at  the  commencement — Tongue  dry  and  brown — Disease  of  twelve  days’ 

duration. 

A man,  twenty-two  years  of  age,  had  been  ill  for  the  last  nine  days,  when  he 
entered  the  hospital;  he  had  at  first  felt  some  shivering,  then  a burning  and 
constant  heat ; no  purging.  At  the  time  of  his  admission  the  countenance  was 
very  calm,  fever  very  moderate,  and  the  general  state  good.  However,  in  the 
midst  of  these  symptoms,  which  indicated  but  a mild  disease,  the  teeth  were 
encrusted,  and  the  tongue  very  dry  and  brown.  (Barley  ptisan  and  emollient 
lavements.) 

On  the  next  day  the  tongue  became  moist,  the  pulse  lost  its  frequency,  and 
he  was  convalescent  in  two  days  after. 

This  case  is  remarkable  for  the  discordance  existing  between  the  state  of  the 
tongue  and  of  the  teeth,  from  which  one  might  apprehend  a most  serious  affec- 
tion, and  the  very  great  mildness  of  the  other  symptoms. 

There  are  some  persons  whose  tongue  becomes  dry  and  brown  in  every 
attack  of  illness,  no  matter  how  slight.  This  happens  principally  in  the  case 
of  aged  persons  ; it  is  also  observed  in  young  persons,  those  particularly  whose 
nervous  system  has  been  harassed  by  excesses,  or  exhausted  by  scanty  food. 
This  state  of  the  tongue  should  caution  us  against  excessive  bleeding. 

Case  52. — Residence  in  Paris  for  eight  months — Excessive  use  of  wine — Shivering  at  the 

commencement ; at  first  a predominance  of  the  general  symptoms — Diarrhoea  towards  the 

end. 

A boy,  fifteen  years  old,  who  had  been  living  in  Paris  for  about  eight  months, 
was  seized  with  a violent  shivering  a little  time  after  he  had  drank  more  wine 
than  usual.  On  the  following  days  he  had  severe  headach,  pain  in  the  pit  of 
the  stomach  ; his  appetite  still  remained  ; bowels  were  constipated,  and  he  had 
alternations  of  heat  and  cold.  He  had  been  keeping  his  bed  for  about  four 
days  previous  to  his  entering  the  hospital.  At  his  admission  he  had  no  head- 
ach, but  some  pain  in  the  back  of  the  neck  and  at  both  shoulders  ; intense  red- 
ness of  the  cheeks  ; dizziness  ; tongue  white,  with  red  points,  and  moist ; thirst 
not  severe  ; some  appetite  ; slight  colicky  pains  ; one  or  two  liquid  stools  every 
twenty-four  hours  for  the  last  two  days  ; pulse  frequent  and  hard  ; skin  very 
hot ; perspiration  over  the  face.  (Demulcent  ptisans.) 

On  the  following  days  there  was  a gradual  diminution  of  the  symptoms,  and 
a progressive  return  to  health. 

* These  different  influences  certainly  act  less  on  any  one  particular  organ  than  on  the  inner- 
vation, whose  powers  they  modify,  and  on  the  blood,  whose  composition  they  have  a tendency 
to  change.  Thus,  before  an  organ  becomes  manifestly  diseased  in  persons  subjected  to  these 
influences,  they  had  produced  a morbid  disposition  in  the  system.  In  this  predisposition,  much 
more  than  in  the  local  lesion,  we  should  seek  for  the  cause  of  the  different  symptoms  which 
accompany  this  lesion.  But  what  is  the  onset  of  this  lesion  itself  ? It  probably  is  the  same 
previous  morbid  state  of  the  innervation  and  the  blood.  Does  not  a moral  excitement  produce 
diarrhoea,  colic,  and  vomiting  I Does  not  the  injection  of  putrid  matter  into  the  veins  occasion 
gastro-enteritis  in  animals  1 


DISEASES  OP  THE  ABDOMEN. 


109 


Here,  again,  the  signs  of  gastro-intestinal  irritation  are  but  little  marked,  and 
it  would  be  difficult  to  say  whether  the  cause  which  seems  to  have  occasioned 
the  disease  had  not  at  first  acted  on  the?  brain  rather  than  on  the  stomach.  In- 
troduce, in  fact,  a certain  quantity  of  alcoholic  liquor  into  the  stomach  of  an 
animal  ; it  is  not  of  gastric  irritation  that  you  will  find  traces,  it  is  not  towards 
the  stomach  that  the  great  functional  disturbances  will  appear,  but  in  the  ner- 
vous centres. 

Case  53. — Residence  in  Paris  for  sixteen  months — At  the  commencement  the  general  symp- 
toms prevailed — At  a later  period  there  was  diarrhoea,  petechise  ; sweats  towards  the  termi- 
nation— Disease  lasted  seventeen  days. 

A shoemaker,  about  seventeen  years  old,  residing  in  Paris  for  sixteen  months, 
had  an  attack  of  fever  and  purging  five  months  before.  On  the  4th  of  August, 
without  any  known  cause,  he  felt  general  illness,  and  an  intense  pain  in  the 
frontal  region.  Up  to  the  10th  the  illness  increased  ; his  bowels  were  consti- 
pated, pulse  frequent  and  full ; skin  hot.  (Barley  ptisan,  flaxseed  lavement.) 

On  the  11th,  felt  himself  better  ; headach  less  ; same  state  of  the  digestive 
passages  ; pulse  frequent ; skin  hot  and  dry. 

On  the  12th,  diarrhoea  for  the  first  time  ; tongue  less  red  ; continuance  of  the 
fever. 

On  the  13lh,  continuance  of  the  diarrhoea  ; tongue  red  and  dry ; fever  less. 
On  the  14th,  profuse  sweat;  tongue  white  and  moist;  diarrhoea  lessened  ; 
pulse  scarcely  frequent. 

On  the  15th,  cessation  of  the  diarrhoea  ; some  petechial  spots  on  the  chest 
and  epigastrium  ; he  was  somewhat  restless  during  the  night;  frequency  of 
pulse  and  heat  of  skin  increased. 

From  the  15th  to  the  20th  very  profuse  sweats  occurred  ; the  petechial  spots 
disappeared  ; the  pulse  lost  its  frequency.  On  the  21st  the  patient  was  very 
well. 

This  disease,  though  rather  severe,  was  still  treated  only  with  diluents  ; care 
was  taken  merely  to  remove  everything  that  might  have  thwarted  the  progress 
of  nature.  At  first  it  was  the  stomach  which  seemed  to  be  principally  affected  ; 
at  a later  period  the  large  intestine  became  irritated  ; the  appearance  of  the 
petechial  spots  coincided  with  an  increase  of  the  fever  ; one  might  then  dread 
the  development  of  ataxo-adynamic  symptoms  ; profuse  sweats  came  on,  and 
from  that  time  the  disease  progressed  towards  resolution.  Were  these  sweats 
critical?  Would  they  have  occurred  if  the  disease,  instead  of  being  left  to  its 
natural  course,  had  been  interfered  with  in  its  progress  by  an  active  treatment? 
Then,  probably,  anothergroup  of  phenomena  would  have  presented  themselves, 
and  probably  the  disease  would  have  taken  another  course,  have  been  attended 
with  other  symptoms,  and  would  have  had  another  mode  of  termination. 

Case  54. — Residence  in  Paris  for  nine  months — Diarrhoea  at  the  time  of  admission — Stupor; 
tongue  dry  and  brown  ; petechise — Gradual  cessation  of  the  symptoms — Continuance  of  the 
petechiee  at  the  time  of  convalescence. 

A locksmith,  twenty-three  years  of  age,  who  had  been  residing  in  Paris  for 
the  last  nine  months,  had  some  purging  for  several  days  back,  when  he  entered 
the  Charite.  At  this  time  he  presented  an  air  of  stupor,  and  had  headach  ; tongue 
red  and  dry,  and  brown  in  the  centre;  abdomen  free  from  pain,  a little  tense; 
purging  diminished.  Pulse  of  moderate  frequency,  unequal  with  respect  to  its 
strength ; skin  covered  with  a profuse  sweat,  red  spots,  a little  prominent,  varying 
from  the  size  of  a grain  of  millet  to  that  of  a small  lentil,  scattered  over  the  ab- 
domen and  chest  (two  blisters  to  the  legs;  barley  ptisan,  emollient  lavement, 
emollient  fomentations  to  the  abdomen).  On  the  evening  of  the  7th  there  were 
sweats  ; pulse  not  frequent ; from  five  to  six  liquid  stools  ; tongue  moist.  On  the 
10 


110 


ANDItAL’S  MEDICAL  CLINIC. 


following  day  tongue  more  moist,  constantly  brown  in  the  centre ; profuse  sweat ; 
pulse  not  frequent,  a little  irregular  ; several  stools  ; some  appetite  ; continuance 
of  the  spots. 

During  the  three  days  following  there  was  cessation  of  the  diarrhoea;  tongue 
natural ; pulse  not  frequent ; continual  sweats.  The  petechiae  were  not  lessened. 
Dating  from  the  12th  there  was  complete  convalesence  ; still  the  petechiae  did 
not  entirely  disappear  till  the  16th.  Symptoms  of  rather  a serious  character 
existed  at  the  time  of  the  patient’s  entering  the  hospital,  though  the  pulse  was 
but  moderately  frequent.  Profuse  sweats  continued  to  take  place  after  the  pulse 
was  entirely  returned  to  its  natural  state.  The  petechiae,  which  had  commenced 
to  show  themselves  at  the  time  the  disease  was  most  intense,  did  not  diminish 
with  it.  These  petechial  spots  survived  in  some  measure  all  the  other  symp- 
toms, and  so  appeared  to  be  entirely  independent  of  them. 

An  entero-colite,  or,  if  you  will,  a dothinenterite,  marked  the  commencement 
of  this  disease  ; the  innervation  was  in  a short  time  rather  seriously  affected. 
The  stupor,  the  brown  appearance  of  the  tongue,  and  the  petechiae,  were  cer- 
tainly not  the  result  of  gastro-intestinal  irritation.  This  irritation  was  one  of  the 
elements  of  the  disease  ; but,  in  my  opinion,  it  did  not  constitute  the  entire  of 
it.  Yet  what  was  done?  No  other  active  treatment,  except  the  application  of 
blisters  to  the  legs,  the  use  of  diluent  drinks,  some  lavements,  and  fomentations 
to  the  abdomen.  No  bloodletting  was  required  to  restore  the  patient  to  health. 

Case  55. — Residence  in  Paris  for  eleven  months — Articular  rheumatism  at  the  commence- 
ment; disappearance  of  the  pains ; continuance  of  the  fever  : subsequently  stupor,  delirium, 
tongue  of  a black  colour;  slight  diarrhoea — Continuance  of  the  disease  for  twenty-seven 
days. 

A medical  student,  twenty-two  years  old,  had  been  in  the  enjoyment  of  good 
health  since  his  coming  to  Paris,  where  he  had  been  residing  for  the  last  eleven 
months.  He  slept  in  an  airy  room.  Had  frequently  indulged  in  venereal  ex- 
cesses. On  the  12th  of  November  he  felt  general  illness,  shivering,  and  some 
lieadach.  On  the  three  days  following  the  same  state  continued,  mouth  was 
clammy,  there  was  loss  of  appetite  and  constipation. 

When  called  to  him,  November  16th,  we  found  him  in  the  following  state  : — 
countenance  pale  and  dejected;  features  drawn,  restless  expression  of  the  phy- 
siognomy, pain  felt  in  moving.  The  tongue  was  loaded  with  a thick  whitish 
coat ; no  thirst ; loss  of  appetite  ; abdomen  soft  and  free  from  pain,  no  alvine 
evacuation  since  the  beginning  of  the  disease.  Pulse  frequent,  not  full ; moderate 
heat  of  skin. 

Seeing  no  precise  indication  present  itself,  we  merely  prescribed  a barley  pti- 
san, two  simple  lavements,  and  diet. 

The  five  days  following  the  patient  remained  in  nearly  the  same  state.  (The 
same  prescription  ; a bath.) 

November  22d,  the  eleventh  day,  features  more  sunk  ; prostration  of  strength 
greater ; his  answers  were  uncertain ; the  tongue,  which  was  protruded  with 
difficulty,  was  covered  with  a greyish  coat,  and  was  very  viscid  ; this  same  coat 
glued  the  teeth  to  each  other.  (Infusion  of  orange-leaves.) 

On  the  twelfth  day  he  had  epistaxis.  On  the  thirteenth  day  tongue  was  dry 
and  covered  with  a black  crust ; air  of  stupor ; delirium  at  intervals.  Pulse 
very  frequent  and  small.  On  the  fourteenth  day  a second  epistaxis,  diarrhcea 
for  the  first  time  ; same  state  in  other  respects.  We  continued  the  simple  diluent 
drinks.  On  the  fifteenth,  sixteenth,  and  seventeenth  days  there  were  several  at- 
tacks of  epistaxis.  Tongue  was  very  dry  and  brown  ; stupor  ; silence  ; delirium 
in  the  night.  (Barley-water,  marsh-mallow  lavements,  frictions  with  warm  vinegar 
to  the  extremities.) 


DISEASES  OF  THE  ABDOMEN". 


Ill 


On  the  eighteenth  and  nineteenth  days,  no  change ; no  epistaxis.  (The  same 
prescription.) 

On  the  twentieth  day  there  was  less  prostration  expressed  in  the  countenance  ; 
the  eye  was  more  natural ; the  tongue  was  a little  moist.  Three  liquid  stools 
since  the  last  twenty-four  hours.  From  the  twenty-first  to  the  twenty-seventh 
day  the  amendment  progressed.  On  the  twenty-seventh  day  the  tongue  was 
moist  and  of  a good  colour;  the  strength  was  improved  ; the  diarrhoea  no  longer 
existed  ; the  pulse  still  retained  a little  frequency,  which  it  lost  on  the  following 
days.  In  the  month  of  December  the  patient  was  restored  to  his  ordinary  state 
of  health. 

The  subject  of  this  case  presented  more  alarming  symptoms  than  the  others. 
He  recovered  under  the  same  treatment.  This  was  one  of  those  cases  in  which 
we  think  it  wise  to  abstain  from  bloodletting.  Though  this  disease  was  not  put 
out  of  its  course  by  any  treatment,  it  terminated  without  the  appearance  of  any 
phenomenon  which  may  be  called  critical. 

The  casesjust  now  detailed  may  be  of  some  use  at  a time  when  the  prevailing 
theories  incline  us  to  take  blood  at  the  onset  and  during  the  course  of  every  fe- 
brile disturbance.  They  show  what  may  be  expected  in  these  diseases,  whether 
light  or  severe,  from  a treatment  purely  expectant. 


ARTICLE  IT. 

TREATMENT  BY  EVACUANTS. 

Of  the  individuals  who  form  the  subject  of  the  cases  contained  under  this 
article  some  merely  presented  the  symptoms  of  that  morbid  state  which  is  known 
by  the  name  of  gastric  and  intestinal  disturbance ; they  had  but  a very  slight 
fever,  some  even  had  none. 

Others,  presenting  nearly  the  same  symptoms  as  the  preceding  patients,  had 
moreover  fever  of  considerable  violence. 

Others,  again,  presented  several  of  the  symptoms  of  what  is  called  the  ady- 
namic state,  when  we  tried  the  effect  of  a vomit. 

Case  56. — Symptoms  of  gastric  disturbance  ; absence  of  fever — An  emetic— Cure. 

A young  man,  seventeen  years  of  age,  born  in  Paris,  presented,  on  entering 
the  Charite,  the  symptoms  of  that  state  of  the  system  which  has  been  designated 
by  the  name  of  lassitude  with  gastric  disturbance  ( courbature  avec  embarras 
gastrique ).  He  had  lost  his  appetite  for  the  last  fifteen  days  ; he  had  a feeling 
of  general  illness,  intense  supra-orbital  headach.  He  complained  of  constant  epi- 
gastric pain  and  of  constipation.  The  tongue  was  yellowish,  mouth  clammy. 
There  was  a total  absence  of  fever.  In  vain  the  patient  had  recourse  to  diluent 
and  demulcent  drinks,  his  state  was  not  improved.  Two  grains  of  tartar  emetic 
were  given  him,  which  acted  very  powerfully  both  upwards  and  downwards. 
At  the  end  of  twenty-four  hours  all  the  morbid  symptoms  had  disappeared,  and 
the  patient  was  restored  to  his  ordinary  state  of  health  ; no  sweat  had  taken 
place. 

Thus  in  this  case  the  employment  of  an  emetic  removed  almost  instantane- 
ously symptoms  which  diet  and  simple  diluents  were  unable  to  remove. 

Case  57. — Headach;  spontaneous  vomiting— Slight  fever — Emetic — Cure. 

A boy,  seventeen  years  of  age,  residing  in  Paris  for  about  five  weeks,  expe- 
rienced, on  the  4th  and  5th  of  October,  some  dizziness  and  pain  of  head.  On 
the  5th  he  vomited  of  his  own  accord  some  bitter  yellow  matters.  On  the  6th 


112 


ANDRAL’S  MEDICAL  CLINIC. 


lie  presented  the  following  state  : supra-orbital  headach,  tongue  white,  bad  taste 
in  the  mouth,  nausea,  sensation  of  general  fatigue,  stools  natural,  very  slight 
fever.  (Eight  grains  of  ipecacuanha,  barley  ptisan,  broths.)  He  vomited  a con- 
siderable quantity  of  a glairy  substance  and  a lumbricus.  On  the  next  day  he 
was  very  well. 

We  have  often  seen,  as  in  this  case,  persons  tormented  with  nausea  and  even 
vomiting,  who  were  not  relieved  till  after  taking  an  emetic.  Then  the  fever  ceased 
and  perfect  health  was  restored. 


Case  58.. — Constipation  of  long  standing;  stercoral  tumour;  fever — A repetition  of  emeto* 

cathartics  ; cure. 

A tailor,  twenty  years  of  age,  who  had  recently  come  from  Bayonne,  had  not 
been  at  stool  for  the  last  fifteen  days,  when  he  entered  the  Charite,  September 
22d.  He  complained  of  colicky  pains.  There  was  found  around  the  umbilicus 
a moveable  tumour,  which  was  considered  by  M.  Lerminier  as  the  result  of  the 
accumulation  of  faeces  in  the  cells  of  the  colon.  The  tongue  was  covered  with 
a yellowish  thick  coat:  pulse  frequent.  (Two  lavements  of  senna  and  sulphate 
of  soda,  of  each  an  ounce.  Linseed  ptisan.) 

A great  quantity  of  very  hard  faeces  was  discharged.  The  day  after  the 
umbilical  tumour  was  gone.  The  pulse*  though  less  frequent,  was  not  yet 
natural.  The  yellowish  coat  of  the  tongue  continued.  Ten  grains  of  ipecacu- 
anha were  prescribed.  The  patient  vomited  but  little,  but  he  went  frequently 
to  stool. 

On  the  24th,  tongue  bright  red,  appetite  good,  pulse  natural.  This  state  con- 
tinued for  the  next  two  days.  On  the  27lh  the  mouth  again  became  clammy ; 
there  were  borborygmi  and  constipation,  slight  frequency  of  the  pulse.  ( Whey, 
with  half  an  ounce  of  sulphate  of  soda.)  Four  or  five  stools  in  the  course  of  the 
day. 

October  1.  The  symptoms  of  gastric  disturbance  still  continued.  Two  pas- 
tilles of  emetine,  each  containing  half  a grain  of  this  substance,  were  given  in  the 
interval  of  a quarter  of  an  hour  between  each.  The  patient  vomited  some  mi- 
nutes after  having  taken  the  second  of  them  : he  had  one  evacuation  by  stool. 
He  soon  left  the  hospital  in  good  health. 

We  shall  remark  in  this  case  the  way  in  which  the  symptoms  returned 
several  times,  which,  on  returning,  were  combated  either  by  an  emetic  or  a 
purgative.  They  did  not  reappear  after  the  last  vomiting  occasioned  by  the 
emetic. 

We  shall  also  call  attention  to  the  tumour  which  was  felt  through  the  abdomi- 
nal parietes,  and  which  consisted  of  hardened  faeces. 

Stercoral  tumours,  similar  to  that  observed  in  the  preceding  case,  have  been 
taken  sometimes  for  sehirrous  tumours.  We  have  seen  a striking  example  of  this 
at  the  Charite  in  an  old  woman,  who  presented  between  the  epigastrium  and 
umbilicus,  a prominent,  knobby  tumour,  which  was  moveable  and  painful.  This 
woman  gave  but  little  information  regarding  her  previous  state.  Being  first  taken 
for  a little  time  into  the  surgical  wards,  she  was  considered  to  be  affected  with 
schirrus  of  the  epiploon.  The  same  opinion  had  been  given  of  the  case  at  the 
central  bureau.  She  was  subsequently  placed  under  M.  Lerminier’s  care.  On 
examining  the  abdomen,  he  soon  recognised,  along  the  course  of  the  colon,  knobby 
tumours  similar  to  the  preceding,  except  that  they  were  smaller.  It  was  soon 
ascertained  that  she  had  not  been  for  a long  time  at  stool.  M.  Lerminier  con- 
sidered these  tumours  owing  to  the  accumulation  of  faeces.  Purgatives  were 
administered  both  up  and  down  ; an  immense  quantity  of  hard  faeces  was  passed, 
and  the  pretended  schirrus  disappeared. 

In  other  cases,  we  have  seen  the  prolonged  accumulation  of  matter  in  the  large 
intestine  give  rise  to  general  tension  of  the  abdomen,  and  to  pains  so  acute  as  to 


DISEASES  OF  THE  ABDOMEN. 


113 


excite  suspicion  of  peritonitis.  We  observed  these  pains  in  their  highest  degree 
of  severity  in  a woman  who  had  been  recently  confined.  When  we  saw  her  for 
the  first  time,  her  countenance  was  pale  ; her  features  very  much  altered,  ex- 
pressed the  most  intense  anxiety  ; the  pulse  was  small  and  very  frequent ; the 
abdomen  was  the  seat  of  very  severe  pains,  which  forced  the  patient  to  scream, 
and  were  increased  on  pressure.  These  pains,  which  were  rather  slight  at  first 
for  some  days,  had  attained,  since  the  last  forty-eight  hours,  this  high  degree  of 
severity.  M.  Lerminier,  on  examining  the  abdomen,  felt  along  the  course  of  the 
colon  knobby,  uneven  tumours,  which  were  moveable  under  the  finger.  The 
patient  also  informed  him  that  for  more  than  twelve  days  her  bowels  had  been 
obstinately  constipated.  Upon  this  M.  Lerminier  suspected  the  real  nature  of 
the  disease  : he  first  gave  a purgative  lavement,  which  brought  away  a consider- 
able quantity  of  very  hard  faeces  : the  pains  were  lessened,  but  did  not  disappear. 
On  the  next  day  an  ounce  of  syrup  of  buckthorn,  with  the  addition  of  four  grains 
of  gamboge,  brought  away  an  enormous  quantity  of  faeces  ; the  pains  disap- 
peared, and  in  twenty-four  hours  after  the  patient  was  restored  to  her  usual  state 
of  health. 


Case  59. — Pleurodynia  at  first ; subsequently  diarrhoea ; absence  of  fever — An  emetic  given 

during  the  existence  of  the  diarrhoea  ; two  days  after,  complete  recovery. 

A mason,  twenty  years  of  age,  who  had  been  residing  in  Paris  for  a year,  felt, 
during  the  last  fifteen  days,  a pain  under  the  left  breast : it  was  increased  by 
percussion  and  strong  inspiration.  He  had  no  cough,  and  breathed  freely.  For 
the  last  ten  or  twelve  days  he  had  some  purging ; his  tongue  was  covered  with 
a thick  yellowish  coat ; he  had  no  fever  ; he  vomited  a worm  the  evening  he  en- 
tered the  hospital.  The  day  after,  8th  of  May,  he  took  twelve  grains  of  ipecacu- 
anha, with  a grain  of  tartar  emetic.  He  vomited  once  a great  quantity  of  yellow 
bile  and  thick  mucus;  he  went  but  four  times  to  stool. 

On  the  9th  the  pain  of  side  was  entirely  gone  ; the  tongue  had  become  clean. 

10th.  The  diarrhoea  was  gone,  the  patient  perfectly  restored,  and  left  the 
hospital  on  the  12th. 

• A new  circumstance  presented  itself  to  us  in  this  case,  namely,  the  administra- 
tion of  an  emetic,  whilst  there  was  diarrhoea,  and  the  cessation  of  this  diarrhoea 
after  the  vomiting. 

This  slight  disease  presents  several  traits  of  resemblance  to  an  affection 
described  by  Stoll  under  the  name  of  bilious  pleurisy : loss  of  appetite,  bitter 
taste  in  the  mouth,  spontaneous  vomiting,  thick  coating  of  the  tongue,  purging, 
and  at  the  same  time  a fixed  pain  in  a point  of  the  thoracic  parietes  ; lastly,  the 
rapid  disappearance  of  the  stitch  in  the  side,  and  of  the  other  symptoms,  after 
tfie  employment  of  an  emetic. 

Case  60. — Symptoms  of  bilious  fever — Inefficacy  of  simple  diluents — Rapid  recovery  after  the 
employment  of  an  emeto-cathartic. 

A sawyer,  twenty-three  years  of  age,  residing  in  Paris  for  the  last  five  months, 
felt,  without  any  known  cause,  on  the  13th  of  August,  some  headach,  nausea,  and 
colic.  These  symptoms  continued  on  the  following  days.  He  was  continually 
drowsy.  Purging  soon  set  in.  To  relieve  it  he  took  a bottle  of  wine  with  three 
hard  eggs.  The  purging  was  accordingly  stopped  for  twenty-four  hours,  but  it 
then  returned.  When  the  patient  entered  the  Charite,  August21st,  he  complained 
of  a severe  frontal  headach,  dizziness,  general  fatigue ; the  tongue  was  whitish, 
bad  taste  in  the  mouth  ; frequent  nausea  took  place;  there  was  a sensation  of 
weight  at  the  epigastrium ; taking  drinks  increased  it,  and  occasional  nausea. 
Two  or  three  watery  yellow  stools  took  place  in  the  twenty-four  hours.  The 
10 * 


114 


AN  DUAL’S  MEDICAL  CLINIC. 


pulse  was  frequent  and  full ; the  skin  was  moist.  (Vegetable  lemonade,  linseed 
lavements,  emollient  fomentations  over  the  epigastrium,  diet.)  On  the  four  days 
following,  the  mouth  became  worse  ; the  tongue  was  very  much  loaded  ; the  same 
symptoms  continued.  The  same  treatment  had  been  employed  each  day. 

On  the  26th  the  patient  took  some  whey,  with  the  addition  of  two  grains  of 
tartar  emetic  and  half  an  ounce  of  sulphate  of  soda.  He  vomited,  and  went 
several  times  to  stool.  On  the  following  day  the  bad  taste  of  the  mouth  was 
gone;  but  a small  whitish  coat  was  observed  on  the  tongue;  pulse  but  of  moder- 
ate frequency.  (Wliey,  with  pulp  of  tamarinds.)  28th  and  29th.  Two  or  three 
stools  in  the  twenty-four  hours.  Complete  cessation  of  the  fever.  30th.  The 
appetite  was  good  ; perfect  recovery. 

The  signs  of  a gastric  affection  were  very  well  marked  in  this  patient.  Diet 
and  simple  emollients  were  ineffectual  to  remove  on  the  one  hand  the  fever,  on 
the  other  hand  the  bad  taste  in  the  mouth,  the  nausea,  the  weight  in  the  epigas- 
trium, the  coating  of  the  tongue,  and,  lastly,  the  purging.  Who  can  help  being 
Struck  with  the  rapid  improvement  which  took  place  as  soon  as  the  patient  took 
an  emeto-cathartic  ? 

Case  61. — Symptoms  of  intense  bilious  fever  ; tendency  of  the  tongue  to  become  dry  ; absence 
of  diarrhoea — Bleeding ; amendment — Still  a continuance  of  the  fever  and  bilious  symptoms — 
Vomiting  and  purging  ; return  to  health. 

A Savoyard,  thirty  years  of  age,  residing  in  Paris  for  the  last  two  years,  skin 
brown,  muscles  well  developed,  felt,  since  the  twelve  days  previous,  a general 
illness  and  some  shivering  ; lie  lost  appetite  ; the  frequency  of  the  stools  was 
not  increased.  He  kept  quiet,  and  observed  strict  diet,  t At  the  time  of  his 
entering  the  Charite,  on  the  10th  of  April,  there  was  intense  headach,  redness 
of  face  with  a yellow  tint  around  the  lips  and  alse*  nasi ; conjunctiva  a little 
yellow  ; tongue  whitish,  dotted  with  red  points,  showing  a tendency  to  become 
dry  ; mouth  very  bitter,  nausea,  pains  in  the  epigastrium,  stools  natural  ; pulse 
frequent,  skin  hot  and  dry.  There  was  in  this  individual  a group  of  inflamma- 
tory symptoms,  not  presented  by  the  patients  already  mentioned.  M.  Lermi- 
nier  accordingly  commenced  by  prescribing  a bleeding  to  the  extent  of  four 
palettes.  The  blood  drawn  was  slightly  buffed. 

On  the  11th  there  was  a perceptible  improvement;  tongue  was  moist;  pulse 
less  frequent.  On  the  12th  the  patient  complained  of  great  weight  of  head,  and 
of  an  intolerably  bitter  taste  in  the  mouth.  The  pulse  was  more  frequent  than 
on  the  day  before  ; he  had  had  one  stool.  (Barley  ptisan.)  On  the  14th  the 
tongue  was  covered  with  a yellowish  coat.  (Six  grains  of  ipecacuanha.)  The 
patient  vomited  a great  quantity  of  yellow  bitter  bile ; he  went  three  times  to 
stool : he  sweated  during  the  night.  ^ 

On  the  next  day,  the  15th,  the  pulse  had  lost  its  frequency;  the  mouth  was 
less  bitter;  the  pain  of  head  was  gone ; the  tongue  was  still  loaded.  Two  grains 
of  tartar  emetic  were  prescribed.  The  patient  did  not  vomit,  but  had  two  copious 
stools  ; he  sweated  that  night.  16th,  the  tongue  resumed  its  natural  appearance  ; 
the  bad  taste  in  the  mouth  was  gone.  l?th,  perfectly  recovered. 

In  this  case  the  employment  of  evacuants  was  preceded  by  a bleeding;  it  ex- 
ercised a favourable  influence  on  the  symptoms.  The  patient,  after  losiug  some 
blood,  was  certainly  better,  but  he  was  not  cured  ; the  pulse  had  not  lost  its  fre- 
quency ; the  pain  of  head  and  bad  taste  in  the  mouth  still  continued.  It  was 
then  that  emetics  were  prescribed  ; ipecacuanha,  given  in  a small  dose,  produced 
copious  vomiting;  tartar  emetic,  afterwards  administered,  merely  purged;  and 
it  was  after  this  evacuation  downwards  that  all  the  morbid  phenomena  finally 
ceased. 


DISEASES  OF  THE  ABDOMEN.  115 

Case  62. — Diarrhoea,  fever,  etc. — Bleeding  and  an  emetic  on  the  same  day — Rapid 

recovery. 

A man,  twenty-two  years  of  age,  residing  in  Paris  for  about  two  months,  felt, 
seven  days  before  his  admission  into  Charite  (11th  April),  general  illness.  He 
had  at  the  same  time  some  shivering.  On  the  12th  he  kept  to  bed.  On  the 
following  day  had  diarrhoea  and  fever. 

Present  state,  April  18th,  tongue  loaded  ; abdomen  a little  tumid,  free  from 
pain;  ten  stools  in  the  twenty-four  hours;  pulse  full  and  frequent ; skin  hot; 
cough  with  catarrhal  expectoration.  (Twenty  leeches  applied  to  the  anus  at 
eight  o’clock  in  the  morning,  ten  grains  of  ipecacuanha  at  noon.)  The  patient 
vomited  once,  and  went  from  twelve  to  fifteen  times  to  stool.  On  the  20th  the 
fever  was  gone ; he  had  but  three  alvine  evacuations.  He  was  soon  quite  well. 

, 

Case  63. — Fever;  tongue  red;  abdominal  pains ; constipation — Employment  of  tartar  emetic — • 
Temporary  amendment ; then  increased  violence  of  symptoms,  which  yielded  to  an  applica- 
tion of  leeches. 

A boy,  sixteen  years  of  age,  who  had  been  residing  in  Paris  for  about  five 
months,  felt  some  abdominal  pains  since  March  15th.  On  the  20th  he  discon- 
tinued to.  work.  He  entered  the  hospital  on  the  28th,  and  complained  of  pain 
over  the  entire  abdomen,  which  was  increased  by  pressure.  Constipation  ; bad 
taste  in  the  mouth tongue  white  at  its  centre,  intensely  red  at  its  edges  and 
apex  ; pulse  frequent;  skin  hot.  (Two  grains  of  tartar  emetic  in  a pint  of  veal 
broth  ; barley  ptisan.)'  The  patient  vomited,  and  went  to  stool  six  times.  At 
five  in  the  evening  there  came  on  an  exacerbation  of  the  fever,  during  which  the 
abdominal  pains  increased.  On  the  29th,  the  pulse  was  scarcely  frequent;  the 
tongue  presented  the  same  appearance.  (Barley  ptisan.) 

On  the  30th  there  was  intense  fever;  tongue  red,  evincing  a tendency  to  be- 
come dry  ; acute  pain  around  the  umbilicus  ; stools  natural ; cough  frequent  and 
painful.  (Ten  leeches  on  either  side  of  the.  chest.) 

On  the  1st  of  April,  there  was  complete  apyrexia ; cough  nearly  gone;  dis- 
appearance of  the  abdominal  pain.  In  a few  days  he  was  completely  well. 

We  cannot  too  strongly  call  attention  to  the  apparently  improved  state  in 
which  we  found  the  patient  the  day  after  he  took  the  emetic.  If  we  had  then 
discontinued  to  watch  the  case,  we  should  have  considered  it  as  proved,  that 
in  this  case,  notwithstanding  the  redness  of  the  tongue,  the  administration  of 
the  tartar  emetic  had  been  attended  with  advantage.  This  improvement,  how- 
ever, was  but  temporary  ; and  two  days  after,  the  exacerbation  of  the  fever,  and 
the  commencing  dryness  of  the  tongue,  clearly  showed  how  wrong  we  would 
have  been  in  relying  on  the  improvement  of  the  preceding  day.  We  have  met 
other  cases  in  which,  as  in  that  now  before  us,  it  was  not  till  two  days  after 
the  employment  of  an  emetic  that  its  bad  effects  were  perceived,  as  if  the  tartar 
emetic,  when  introduced  into  the  digestive  tube,  occasioned  in  some  persons  a 
kind  of  irritation  which  was  not  indicated  by  the  symptoms  till  after  the  lapse 
of  a certain  time.  We  shall  here  make  a remark  which  may  not  be  considered 
out  of  place,  namely,  that  among  the  persons  to  whom  tartar  emetic  was  given 
according  to  Rasori’s  method,  we  have  seen  some  who,  after  having  borne  for 
several  days  twenty  or  thirty  grains  of  tartar  emetic  daily  with  impunity,  began 
to  manifest  signs  of  gastro-intestinal  irritation  precisely  at  the  period  when  the 
employment  of  this  medicine  was  suspended,  or  even  some  time  after  its  use 
had  been  wholly  discontinued. 

Case  64 — Suppressed  perspiration — Remittent  fever  mild  at  the  commencement ; at  a sub- 
sequent period,  dry  tongue,  diarrhoea,  prostration  ; miliary  eruption — The  expectant  treat- 
ment used  at  first ; then  purgatives ; bitters  towards  the  termination. 

A mason,  fifty-three  years  of  age,  had  immersed  himself  in  cold  water,  whilst 


11 G 


ANDRAL’S  MEDICAL  CLINIC. 


* 

he  was  in  a state  of  perspiration,  on  the  evening  of  the  29th  of  July.  He  slept 
well,  and  felt  nothing  particular  on  the  next  day  till  about  three  o’clock  in  the 
afternoon.  He  was  then  seized  with  a violent  shivering,  which  was  followed 
by  great  heat  and  profuse  perspiration  during  the  night.  From  the  30th  of 
July  to  the  6th  of  August  he  had  a similar  attack  every  day  ; in  the  morning  he 
was  very  well,  and  continued  to  eat  his  meals  and  to  work  till  the  hour  of  shi- 
vering. On  the  morning  of  the  7th.  he  felt  ill ; the  shivering,  which  came  on  at 
the  usual  hour,  was  followed  by  heat,  and  not  by  any  sweat.  On  the  8th  he  felt 
a burning  heat  of  skin  during  the  entire  day,  and  kept  his  bed. 

On  the  10th  he  entered  the  Charite,  and  presented  the  following  state  : 
expression  of  the  face  natural,  tongue  red  and  dry,  thirst,  loss  of  appetite,  con- 
stipation, abdomen  free  from  pain,  pulse  frequent  and  hard,  skin  hot  anil  dry, 
breathing  a little  hurried  ; five  or  six  red,  lenticular  spots,  prominent  to  the 
touch,  on  the  epigastrium  and  lower  part  of  the  sternum.  (Barley  ptisan  with 
oxymel,  emollient  lavement.)  In  the  course  of  the  day  the  state  of  the  patient 
underwent  no  change. 

11th.  Tongue  red  and  dry,  and  exhibited  a tendency  to  be  incrusted  ; no 
stool ; pulse  hard,  moderately  frequent;  slight  moisture  ; same  character  of  the 
breathing,  spots  more  numerous.  (Same  prescription.) 

12th.  Air  of  stupor,  meteorism,  same  state  of  tongue,  no  stools,  disappear- 
ance of  the  spots.  (.Whey,  with  tamarinds,  broths.) 

13th.  Great  drowsiness,  answers  distinct ; tongue  dry,  cleft,  presenting  at 
its  centre  an  appearance  resembling  burned  cream.  The  tamarinds  had  not 
overcome  the  constipation.  (Half  an  ounce  of  sulphate  of  soda  in  the  whey, 
barley  ptisan  with  oxymel,  emollient  lavement,  broths.)  Only  one  stool  up  to 
the  following  morning  ; the  patient  continued  drowsy  all  the  day. 

14th.  The  tendency  to  coma  continued.  Same  state  of  tongue.  Breathing 
always  a little  hurried.  Some  crepitous  rale  was  heard  in  different  points  of 
the  chest.  (Blister  to  the  sternum.) 

From  the  15th  to  the  20th  the  state  of  the  patient  underwent  no  change.  He 
had  still  strength  enough  to  sit  up.  On  the  20th  a slight  diarrhoea  set  in  ; on 
this  same  day  some  sudamina  appeared  on  the  abdomen  ; at  the  same  time 
another  eruption  showed  itself.  The  lower  part  of  the  sternum,  the  left  flank, 
and  left  side  of  the  chest  were  covered  with  a multitude  of  small  red,  confluent 
patches,  surmounted  for  the  most  part  by  miliary  transparent  vesicles. 

On  the  day  after,  the  double  eruption  continued,  as  well  as  the  diarrhoea. 
The  tongue  was  moist,  pulse  less  frequent. 

From  the  21st  to  the  24th  the  sudamina  and  miliary  pustules  declined. 
The  tongue  was  now  natural,  still  the  air  of  stupor  did  not  cease  ; the  patient 
seemed  both  physically  and  morally  benumbed.  The  crepitous  rale,  which 
was  heard  posteriorly  on  both  sides  of  the  chest,  seemed  to  indicate  oedema  of 
the  lungs.  The  pulse  still  retained  some  frequency  and  the  skin  some  heat. 
The  diarrhoea  had  ceased.  Up  to  this  period  the  patient  had  taken  nothing  but 
some  demulcent  ptisans.  M.  Lerminier  prescribed  the  compound  hydromel, 
and  a strong  decoction  of  polygala  root. 

On  the  following  days,  under  the  influence  of  this  new  treatment,  a very 
rapid  improvement  took  place  ; the  crepitous  rale  ceased,  the  strength  re- 
turned, the  natural  expression  of  the  countenance  was  restored,  and  the  patient 
soon  left  the  hospital  perfectly  recovered. 

This  affection  commenced  by  a quotidian  intermittent,  evidently  produced  by 
the  combined  impression  of  cold  and  moisture  on  the  skin.  At  the  end  of  the 
eighth  fit  this  intermittent  fever  was  changed  into  a continued  fever,  with  red- 
ness and  dryness  of  the  tongue  and  a petechial  eruption.  Not  till  fourteen  days 
after  the  invasion  of  the  continued  fever,  some  diarrhoea  set  in  at  the  same  time 
that  sudamina  and  a miliary  eruption  appeared.  From  the  simultaneous  ap- 


DISEASES  OF  THE  ABDOMEN. 


117 

pearance  of  these  three  phenomena  we  may  date  the  occurrence  of  a perceptible 
amendment. 

The  patient  took  laxatives  several  times  whilst  the  tongue  was  dry,  and  he 
was  plunged  into  a state  of  stupor.  Such  is  the  treatment  adopted  in  similar 
cases  by  English  physicians.  Only  one  blister  was  applied  to  the  sternum  at  a 
time  when  the  respiration  was  perceptibly  impeded.  Bloodletting  was  not  re- 
sorted to.  But  when  the  disease  was  now  become  less  severe,  and  when  the 
predominant  affection  of  the  patient  was  a state  of  languor  of  the  entire  system, 
combined  with  pulmonary  engorgement,  recourse  was  had  to  tonic  treatment. 
We  have  seen  with  what  rapidity  the  crepitous  rale  disappeared  as  soon  as  the 
polygala  was  given.  Was  it  not  by  raising  the  general  strength  of  the  patient, 
that  the  serous  engorgement  of  the  lungs  was  removed  ? If  this  latter  phenomenon 
has  been  considered  as  a product  of  pulmonary  irritation , such  a treatment 
would  have  been  avoided,  we  should  have  had  recourse  to  bleeding  and  to  revul- 
sives ; and  it  is  a question  with  me,  whether  so  favourable  a termination  would 
have  been  obtained. 


ARTICLE  III. 

TREATMENT  BY  ANTIPHLOGISTICS  (BLOODLETTING  AND  REVULSIVES). 

Case  65. — Fever;  diarrhoea;  tongue  dry ; two  applications  of  leeches  to  the  anus;  one 

venesection. 

A baker,  eighteen  years  old,  of  a strong  constitution,  had  supped  as  usual  on 
the  28th  of  October.  Three  hours  afterwards  he  was  seized  with  an  intense 
supra-orbital  headach  ; he  felt  himself  benumbed  ; he  then  had  a violent  shiver- 
ing, which  was  followed  by  great  heat  and  perspiration.  On  the  29th  the  fever 
was  very  high;  the  patient  went  more  than  thirty  times  to  stool  in  the  course 
of  the  day.  The  abdomen  was  free  from  pain.  This  state  continued  during 
the  following  days.  He  entered  the  Charite  November  1st,  and  on  the  2d  pre- 
sented the  following  state  : — 

Headach  ; face  red  ; eyes  very  bright;  general  debility;  tongue  yellowish, 
and  a little  dry  ; thirst ; purging  as  severe  as  at  the  commencement;  alvine  de- 
jections watery,  and  not  accompanied  with  tenesmus;  abdomen  free  from  pain  ; 
pulse  full,  and  moderately  frequent ; not  much  heat  of  skin.  (Thirty  leeches 
to  the  anus  ; barley  ptisan,  with  mucilage  ; strict  diet.) 

The  diarrhoea  was  considerably  diminished  ; the  patient  went  but  four  times 
to  stool  in  the  following  twenty-four  hours.  At  night  he  felt  extremely  hot,  and 
did  not  perspire. 

On  the  morning  of  the  3d  the  headach  was  gone,  but  the  tongue  was  dry  ; 
pulse  strong;  skin  hot  and  dry.  Thus,  though  the  diarrhoea  was  lessened  in 
consequence,  no  doubt,  of  the  leeches  applied  to  the  anus,  the  fever  had  in- 
creased. He  was  bled  to  the  amount  of  two  palettes.  The  same  ptisan  was 
continued,  and  strict  diet  enjoined. 

The  purging  was  greater  than  on  the  preceding  day  (from  eight  to  nine  stools). 
He  was  very  much  disturbed  during  the  night. 

On  the  4th  the  fever  still  continued  ; the  tongue  was  moist  and  red  ; abdomen 
always  free  from  pain ; ten  additional  leeches  were  applied  to  the  anus.  As 
those  first  applied,  they  had  undoubted  influence  on  the  purging  ; he  had  no 
stool  till  the  following  morning,  the  5th  of  November,  which  was  the  ninth  day 
of  the  disease.  He  had  had  a tranquil  night ; the  tongue  had  lost  its  redness; 
the  skin  was  a little  hot,  and  the  pulse  was  scarcely  frequent.  The  patient  was 
infinitely  better  ; the  purging  did  not  return  ; and  on  the  10th  of  November  he 
was  perfectly  recovered. 


118 


ANDRAL’S  MEDICAL  CLINIC. 


In  this  case  we  see  the  morbid  symptoms  at  first  become  aggravated,  the  fever 
become  more  severe,  the  tongue  become  red,  &c.,  notwithstanding  the  very 
active  employment  of  an  antiphlogistic  treatment.  Thus  the  leeches  did  not 
carry  off  the  disease,  which,  during  their  employment,  still  continued  its  pro- 
gress, and  became  worse.  The  only  improvement  was  in  the  purging,  and  in 
this  case  the  bleeding  from  the  anus  acted  more  effectually  on  it  than  the  vene- 
section. We  are  not  certain  that  the  general  improvement  which  followed  the 
second  application  of  leeches  was  owing  to  this  application. 

Case  66. — Acute  bronchitis ; pleurodynia;  tongue  red  ; fever;  critical  sweats — Bloodletting; 

leeches  to  the  chest. 

A man,  thirty-one  years  old,  who  had  been  residing  in  Paris  for  the  last  four 
years,  brown  skin,  black  hair,  muscles  not  much  developed,  usually  in  the  enjoy- 
ment of  good  health,  felt,  on  the  16th  of  October,  painful  tension  of  the  right 
cheek.  He  continued  his  usual  work.  This  tension  increased  on  the  following 
day  ; he  thought  himself  somewhat  feverish  ; he  had  headach  ; an  aversion  to 
food.  On  the  18th  the  pain  of  cheek  disappeared,  but  he  felt  rather  an  acute 
pain  in  the  inferior  and  lateral  part  of  the  chest  on  the  right  side  towards  the 
loins.  He  kept  his  bed  on  the  20th  of  October.  On  the  22d  he  entered  the 
hospital,  presenting  the  following  state  : — 

Supra-orbital  headach  ; yellowish  tint  of  face  ; eyes  heavy  ; pains  in  the  limbs ; 
pain  in  the  site  of  the  three  last  ribs,  extending  to  the  right  flank  and  loins,  and 
increased  by  pressure  and  cough,  but  not  by  the  inspiratory  motions  ; tongue 
red  ; thirst;  bad  taste  in  the  mouth;  abdomen  free  from  pain;  constipation; 
pulse  strong,  not  frequent;  heat  of  skin  moderate  ; breathing  free  ; slight  cough  ; 
expectoration  that  of  acute  catarrh  ; percussion  sonorous  in  every  part;  sibilous 
rale  on  both  sides  below  the  clavicles  (a  sign  of  simple  pulmonary  catarrh). 
(Twelve  leeches  to  the  right  side  of  the  chest ; venesection  to  the  extent  of  two 
palettes  ; infusion  of  violets.) 

On  the  23d  the  blood  drawn  the  day  before  formed  into  a coagulum  of  but 
little  consistence,  and  was  not  buffed.  The  patient  slept  tolerably  well  ; pain 
of  side  gone,  as  also  that  of  the  head  ; tongue  no  longer  red  ; thirst  less  ; fre- 
quent horborygmi  in  the  abdomen  ; he  had  had  no  stool ; the  pulse  was  strong, 
and  always  a little  frequent ; slight  sweats  came  on  during  the  night  for  the  first 
time  (on  the  night  of  the  seventh  day). 

On  the  24th  he  found  himself  very  well;  he  still  sweated  a little  during  the 
night;  fever  altogether  gone  ; appetite  returned.  (Bourrache  oximellee  ; rice 
cream  ; broths.) 

On  the  25th,  profuse  sweats  during  the  night,  but  they  did  not  appear  on  the 
following  days.  The  patient,  complaining  of  troublesome  borborygrni  and 
constipation,  took,  during  two  days,  two  glasses  of  a purging  mixture.  He  left 
the  hospital  on  the  1st  of  November. 

The  continued  fever  which  forms  the  subject  of  this  case  commenced  by  a 
fluxion  in  the  right  cheek,  which,  at  the  end  of  three  days,  was  succeeded  by  a 
pain  in  the  thoracic  parietes  and  the  flank  of  the  right  side ; at  the  same  time 
there  was  fever,  headach,  loss  of  appetite,  cough,  yellowness  of  the  face.  Stoll 
would  have  called  this  group  of  symptoms  by  the  name  of  bilious  pleurisy,  and 
he  would  have  given  a vomit ; but  to  us  the  seat  of  the  pain  appeared  to  be  in 
the  external  parts  of  the  chest,  and  the  cough  was  the  effect  of  simple  pulmo- 
nary catarrh. 

The  sweats,  which  came  on  during  the  night  of  the  seventh  day,  and  which 
continued  on  the  following  days,  seemed  to  be  critical. 

The  local  and  general  bleeding  accelerated  the  resolution  of  the  disease. 
The  pain  of  side  yielded  to  the  application  of  the  leeches.  It  is  only  by  mere 
hypothesis  that  we  could,  in  this  case,  give  to  the  fever  a very  determinate  seat, 


DISEASES  OF  THE  ABDOMEN. 


119 


or  a manifest  origin.  Now,  in  practice  nothing  is  more  common  than  such 
cases ; nothing  is  more  common  than  thus  to  observe,  in  the  midst  of  a febrile 
state,  whether  temporary  or  permanent,  a rapid  succession  of  several  local  affec- 
tions which  coincide  with  the  fever,  without  its  being  always  possible  to  deter- 
mine their  relation  to  it,  and  which  are  all  probably  connected  by  a link  which 
escapes  us.  An  instance  of  this  occurs  in  the  following  case,  which  may  be 
advantageously  compared  with  the  case  just  detailed  : — 

A young  man  presented  himself  at  the  central  Bureau,  still  bearing,  on  several 
points  of  the  skin,  traces  of  numerous  furuncles,  which  he  had  previously  had 
in  succession  on  the  neck,  axilla,  back,  abdomen,  perineum,  and  thighs.  Before 
this  eruption  he  had  a swelling  on  one  of  the  cheeks,  without  any  redness  of 
skin,  which  he  calls  a fluxion.  When  he  presented  himself  at  the  central 
Bureau  this  person  was  affected  with  a well  marked  urticaria,  and  he  stated  that 
he  had  had  a similar  eruption  several  times.  He  entered  the  Charite,  the  urti- 
caria disappeared,  and  at  the  same  time  rheumatism,  attended  with  fever,  mani- 
fested itself  at  the  three  great  articulations  of  the  upper  extremity  of  the  left 
side.  For  this,  tartar  emetic,  in  large  doses,  and  bleeding,  were  prescribed. 
At  the  end  of  five  or  six  days  the  rheumatism  disappeared,  but  the  day  after 
erysipelas  of  the  face  came  on.  It  went  through  its  usual  stages,  and,  as  no 
other  affection  complicated  it,  no  active  treatment  was  employed.  The  patient 
appeared  convalescent,  when  one  morning  he  complained  of  a slight  pain 
towards  the  middle  of  the  left  scapula;  a little  hardness  was  observed  here 
without  any  redness  of  the  skin.  On  the  day  after,  in  this  same  part,  wherein, 
twenty-four  hours  before,  there  was  nothing  but  a slight  almost  imperceptible 
swelling,  we  found  an  enormous  abscess,  which  in  the  course  of  the  next 
twenty-four  hours  became  still  larger.  The  skin  was  not  red,  and  the  pain  was 
so  moderate  that  the  patient  continued  to  lie  on  his  back.  He  then  passed  into 
the  surgical  wards,  and  we  lost  sight  of  him. 

Case  67. — Remittent  fever  ; diarrhoea  ; symptoms  of  pneumonia  ; three  bleedings  employed. 

A locksmith,  twenty-three  years  old,  who  resided  in  Paris  for  the  last  two 
months,  and  ordinarily  enjoyed  good  health,  had  an  attack  of  indigestion,  two 
days  before,  after  drinking  some  bad  wine.  In  the  night  he  vomited,  and  went 
several  times  to  stool.  On  the  following. days  the  diarrhoea  continued  ; he  had 
an  attack  of  shivering  every  evening,  and  perspired  at  night ; his  skin  was  very 
hot,  and  he  was  very  ill  during  the  day. 

At  his  admission  his  face  was  a little  red  ; tongue  foul,  slightly  red  at  the 
point ; bad  taste  in  the  mouth  ; abdomen  large  ; skin  hot ; pulse  not  very  frequent ; 
cough  violent  and  frequent ; sputa  those  of  acute  catarrh.  (Two  palettes  of 
blood  were  taken  from  him.)  Blood  not  buffed  ; but  the  next  day  the  sputa 
were  become  viscid,  and  presented  a rust-coloured  tint.  The  chest,  when  per- 
1 cussed,  sounded  well  in  every  part ; everywhere,  too,  the  respiration  was  clear ; 

there  was  but  slight  dyspnoea  ; still,  from  the  character  of  the  sputa,  the  existence 
h of  pneumonia  was  undoubted  ; the  pulse  was  become  more  frequent.  (A  second 
i bleeding.)  This  blood  presented  a thick  buffy  coat ; the  sputa,  which  were 
always  viscid,  had  lost  their  rust-coloured  tint ; the  fever  was  high  ; the  tongue 
, red,  and  showed  some  tendency  to  become  dry  ; the  diarrhoea  continued.  This 
iL  group  of  inflammatory  symptoms  was  combated  by  a third  bleeding  ; it  presented 
as  thick  a buffy  coat  as  the  second.  The  improvement  which  followed  it  was 
remarkable.  On  the  next  day  (September  21st),  the  sputa  again  became  those 
of  simple  catarrh  ; the  tongue  was  moist,  and  of  a bright  red  colour  ; pulse  was 
moderately  frequent ; the  skin  was  covered  with  a little  moisture  ; the  diarrhoea 
had  not  diminished.  The  patient  left  the  hospital  quite  well  on  the  29th. 

Bloodletting  was  indicated  in  this  case  more  than  in  any  of  the  preceding  ; 


120 


ANDRAL’S  MEDICAL  CLINIC. 


the  vein  was  opened  three  times.  The  first  bleeding  did  not  prevent  the  disease 
from  developing  itself ; the  character  of  the  sputa  alone  was  modified  after  the 
second  ; and  it  was  not  till  after  the  third  that  a manifest  and  permanent  improve- 
ment was  observed. 

Thus,  in  recapitulating  the  preceding  cases  with  respect  to  the  therapeutic 
results  which  may  be  deduced  from  them,  we  are  led  to  conclude,  that,  to  combat 
the  diseases  of  the  nature  of  those  which  form  the  subject  of  these  cases,  blood- 
letting has  not  all  the  efficacy  generally  attributed  to  it.  Several  patients,  who 
were  enjoined  strict  diet  and  rest,  recovered  as  promptly  as  those  who  were 
bled.  In  others,  after  the  bleeding,  the  disease  still  continued  its  course,  and 
it  was  only  by  degrees  that  its  solution  was  effected.  In  others  there  was  but 
a temporary  remission.;  after  which  there  was  again  an  exacerbation.  In  no 
one  instance  did  the  disease  yield  immediately  after  the  bleeding.  However,  it 
is  reasonable  to  suppose  that,  among  these  patients,  there  were  some  in  whom 
the  bleeding  had  the  effect  of  preventing  the  symptoms  from  becoming  aggra- 
vated, if  it  did  not  remove  them.* 

Case  68. — At  first  intense  shivering,  followed  by  heat  and  sweat ; stitch  in  the  side  ; delirium, 
petechia? ; great  prostration — During  the  first  days  of  the  affection  leeches  to  the  epigas- 
trium. 

A.  mason,  nineteen  years  old,  residing  in  Paris  for  the  last  two  years,  of  rather 
delicate  constitution,  had  gone  to  bed  very  well  on  21st  of  June.  Nothing 
unusual  had  happened  to  him  during  the  day.  On  the  22d,  when  getting  up, 
he  felt  some  headach,  general  illness,  and  great  lassitude  ; still  he  went  to  work 
as  usual,  but  violent  shivering  soon  obliged  him  to  desist.  He  went  to  bed  ; 
the  fever  was  succeeded  by  burning  heat ; all  the  night  he  sweated  profusely. 
On  the  five  days  following  he  was,  he  stated,  almost  constantly  in  a state  of 
perspiration.  He  had  entirely  lost  his  appetite  ; did  not  vomit ; bowels  were 
constipated ; he  had  also  a slight  cough.  On  the  25th  leeches  were  applied  to 
the  epigastrium.  Having  entered  the  Charite  on  the  evening  of  the  28th  June, 
he  stated,  that,  for  the  last  few  hours,  he  felt  below  the  left  breast  an  acute  pain, 
which  was  increased  by  pressure.  The  respiration  was  impeded  ; there  was 
considerable  fever;  he  was  bled  to  the  amount  of  three  palettes  ; the  blood  drawn 
was  covered  with  a thick  buffy  coat.  During  the  night  the  patient  raved. 

On  the  following  morning  he  no  longer  presented  that  state  of  general  excite- 
ment which  was  observable  the  evening  before  ; the  pain  of  side  was  gone  ; the 
respiration  was  tranquil;  cough  not  very  frequent;  the  sputa  presented  no  parti- 
cular characters  ; pulse  moderately  frequent ; but,  what  was  particularly  remark- 
able, was  the  extreme  dejection  expressed  in  his  features,  a general  debility,  such 
that  the  slightest  change  of  position  was  very  painful  ; the  tongue  a little  loaded  ; 
mouth  clammy;  the  lips  and  teeth  dry  ; abdomen  free  from  pain  ; there  had 
been  no  stool  since  the  last  two  days  ; skin  not  hot ; several  rose-coloured  spots, 
as  large  as  a flea-bite,  and  slightly  projecting,  were  scattered  over  the  chest. 
(Violette  oximellee,  emollient  lavement,  broths.)  No  stool  was  obtained  by 
the  lavement.  In  the  evening  there  was  a profuse  sweat ; at  night  the  delirium 
reappeared. 

Next  day  the  expression  of  the  face  more  natural;  intellect  perfect  ; com- 
plete apyrexia.  From  this  time  no  bad  symptom  presented  itself;  convalescence 
was  speedy  ; and  he  left  the  hospital  in  a few  days. 

There  are  some  circumstances  in  this  case  not  devoid  of  interest.  The  onset 
was  that  of  an  intermittent  fever  ; yet,  whilst  in  this  affection,  the  shivering 
comes  on  most  usually  in  the  midst  of  a perfect  state  of  health,  it  was  here  pre- 

* M.  Louis  has  published  Observations  on  Bloodletting  confirmatory  of  ours.  ( Archives  do 
Medicine.  November,  1828.) 


DISEASES  OF  THE  ABDOMEN. 


121 


ceded  by  general  indisposition  and  spontaneous  lassitude.  The  fever  continued 
'on  the  following  days  without  any  other  local  symptom  except  anorexia  and  a 
slight  cough.  Still,  on  the  sixth  day,  more  marked  symptoms  came  on  with 
respect  to  the  Chest,  and  there  was  a threatening  of  pleuro-pneumonia.  He  was 
bled  ; the  symptoms  of  pulmonic  inflammation  disappeared,  and  the  delirium, 
which  came  on  during  the  night,  indicated  that  the  brain  was  now  become  the 
seat  of  irritation.  From  the  succeeding  day  all  signs  of  inflammation  ceased  ; 
there  was  scarcely  any  fever,  and  we  were  particularly  struck  by  the  symptoms 
of  great  prostration,  with  the  appearance  of  petechiae.  The  prognosis  seemed 
very  unfavourable  ; the  return  of  the  delirium  on  the  following  night  confirmed 
our  fears,  but,  fortunately,  they  were  not  well  founded.  After  two  days  the 
prostration  was  gone  ; the  spots  disappeared,  the  fever  entirely  ceased,  and  the 
patient  became  convalescent.  What  would  have  been  the  consequence  if,  in 
order  to  combat  this  prostration  and  delirium,  bloodletting  had  been  employed? 
In  my  opinion  it  would  only  have  aggravated  these  symptoms,  as  we  have  seen 
on  many  similar  occasions.  We  may  remark  that,  during  the  existence  of  these 
symptoms,  a little  broth  was  allowed.  How,  in  this  rapid  succession  of  symp- 
toms, are  we  to  trace  the  course  of  a disease  such  as  it  is  found  described  in 
books  ? 


ARTICLE  IV. 

TREATMENT  BY  TONICS. 

Case  69.  — Recent  arrival  in  Paris  — At  first  headach  ; symptoms  of  what  is  called  inflam- 
matory fever  ; afterwards  nervous  symptoms ; stupor;  involuntary  stools;  petechiae  — At 
the  beginning  bleeding  and  strict  diet ; then  quinquina  and  broths. 

A joiner,  twenty-two  years  of  age,  residing  in  Paris  only  for  the  last  two 
months,  with  brown  hair  and  small  muscle,  felt  a great  pain  of  head,  without 
any  known  cause,  on  the  16th  of  July.  On  the  following  day  there  was  a 
continuance  of  the  headach  ; pain  in  the  epigastrium  ; loss  of  appetite  ; nausea  ; 
temporary  shivering  ; slight  cough  ; pain  in  the  throat ; constipation.  He 
remained  in  this  intermediate  state,  between  health  and  sickness,  up  to  the 
22d.  He  kept  at  rest,  and  observed  strict  diet.  He  entered  the  Charite  on 
the  22d. 

The  next  morning  his  face  was  flushed  ; eyes  bright  and  injected  ; the  eye- 
lids, weighed  down,  were  raised  with  difficulty  ; violent  frontal  headach  ; diz- 
ziness ; tinnitus  aurium  indicated  a considerable  afflux  of  blood  towards  the 
brain  ; the  tongue  was  covered  with  a whitish  thick  coat;  there  was  complete 
loss  of  appetite,  and  some  thirst.  The  abdomen  was  the  seat  of  general  pain, 
which  was  increased  by  taking  drink.  On  the  preceding  day  there  had  been 
a stool  for  the  first  time  since  the  last  six  days  ; the  pulse  was  frequent  and 
full ; the  skin  was  hot ; there  was  a slight  cough. 

This  group  of  inflammatory  symptoms  was  sufficiently  marked  to  indicate  a 
bloodletting.  (He  was  bled  to  the  extent  of  three  palettes  ; whey  with  tama- 
rinds; emollient  lavement;  strict  diet.)  The  blood  drawn  from  the  vein  re- 
sembled a large  coagulum  without  a buffy  coat. 

The  three  following  days  there  was  no  perceptible  change ; one  stool  every 
twenty-four  hours. 

On  the  night  of  the  26th  several  liquid  stools  occurred,  preceded  by  slight 
colics.  On  the  27th  the  abdomen  was  a little  tympanitic  and  painful ; the 
cough,  which  was  very  slight  on  the  preceding  days,  had  become  more  severe 
and  more  frequent ; the  breathing  was  short ; speech  accompanied  with  panting  ; 
the  expectoration  was  purely  catarrhal  ; auscultation  and  percussion  afforded 
11 


122 


ANDRAL’S  MEDICAL  CLINIC. 


no  information  ; the  heat  of  skin  was  not  considerable,  and  the  frequency  of 
the  pulse  was  moderate  ; some  round  lenticular  spots,  resembling  the  rust  of 
iron  in  colour,  appearing  a little  prominent  to  the  touch,  were  scattered  over 
the  chest  and  abdomen.  (Twelve  leeches  to  the  anus  ; barley  ptisan  ; mucila- 
ginous mixture.) 

On  the  next  day  the  breathing  was  more  free  ; cough  diminished ; the  abdo- 
minal pain  disappeared  after  the  application  of  the  leeches  ; the  spots  had  in- 
creased ; thirst  more  intense  ; the  lips  were  dried  ; from  ten  to  twelve  stools 
since  the  last  twenty-four  hours. 

On  the  29th  the  tongue  was  red,  for  the  first  time,  on  the  edges  and  at  the 
apex  ; the  pulse  was  very  frequent.  (Twelve  leeches  to  the  anus.) 

On  the  30th  he  had  an  anxious  and  distracted  air ; eyes  indifferent  to  sur- 
rounding objects  ; the  lower  jaw  occasionally  performed  some  lateral  move- 
ments. When  the  patient  was  interrogated,  extreme  irregularity  was  observed 
in  his  ideas  ; he  appeared  to  be  in  a state  bordering  on  delirium  ; he  had  had 
two  or  three  involuntary  stools  ; the  appearance  of  the  tongue  was  now  again 
natural ; the  spots,  confluent  in  the  chest  and  abdomen,  were  extended  to  the 
neck  and  arms.  (Two  blisters  to  the  legs  ; barley  ptisan  ; emollient  lavement; 
broth.)  31st.  Intellectual  faculties  were  now  clear;  still  the  air  of  distraction 
continued. 

August  1st,  an  air  of  stupor  ; diarrhcea  diminished.  In  the  course  of  the  day 
the  patient  was  frequently  speaking  to  himself;  the  skin  was  hot,  and  constantly 
dry.  August  2d,  stupor  increased  ; ideas  very  dull ; lost  of  memory  ; speech 
embarrassed,  as  if  the  tongue  were  dry,  yet  it  was  moist  and  red,  as  in  a state 
of  health  ; three  or  four  liquid  stools,  small  in  quantity  ; the  pulse  was  readily 
compressed ; in  other  respects  it  preserved  the  same  character.  The  confluent 
eruption  covered  the  abdomen,  chest,  and  neck;  the  spots  on  the  arms  had  dis- 
appeared. (Diluent  ptisans  continued.) 

From  the  3d  to  the  6th  the  stupor,  sinking  of  the  features,  and  debilitated 
state  of  the  intellect,  increased  ; the  other  symptoms  remained  the  same. 

On  the  7th  the  patient  took,  for  the  first  time,  half  an  ounce  of  extract  of 
quinquina  in  a mucilaginous  potion.  This  was  continued  on  the  8th  and  9th  ; 
and  on  the  10th  a pint  of  aqueous  infusion  of  quinquina  was  added  to  the  pre- 
scription ; broths. 

From  the  10th  to  the  13th  the  purging  ceased  ; one  hard  evacuation  took 
place  every  twenty-four #hours  ; the  tongue  had  an  excellent  appearance  ; the 
abdomen  was  soft  and  free  from  pain  ; the  intellectual  faculties  resumed  their 
usual  energy  ; the  air  of  stupor  was  gone  ; the  spots  had  disappeared,  and  in 
the  parts  where  they  had  existed  desquamation  of  the  cuticle  was  observed  ; 
the  pulse  became  less  frequent.  This  favourable  change  took  place  during  the 
administration  of  tonics. 

On  the  14th  the  pulse  had  entirely  lost  its  frequency,  and  the  skin  its 
heat.  From  this  time  the  patient  may  be  considered  as  convalescent.  The 
extract  of  quinquina  was  suppressed,  but  its  aqueous  infusion  was  continued 
for  eight  or  ten  days  longer.  The  patient  left  the  hospital  on  the  1st  of 
September. 

This  case  presents  an  instance  of  a very  confluent  and  very  extensive  pete- 
chial eruption.  Such  eruptions  are  but  rarely  observed.  It  appeared  at  the 
same  time  as  the  ataxo-adynamic  symptoms,  and  faded  according  as  the  latter 
diminished.  The  desquamation  of  the  epidermis,  which  marked  the  termina- 
tion of  this  eruption,  gives  ita  trait  of  resemblance  to  measles  or  scarlatina.  When 
the  patient  entered  the  hospital  it  would  have  been  difficult  to  say  positively 
whether  any  one  organ  was  more  the  seat  of  lesion  than  another.  It  appeared 
that  the  brain,  lungs,  and  abdominal  viscera,  were  all  in  some  measure  threat- 
ened with  inflammation.  In  the  midst  of  this  general  derangement  of  the  entire 


DISEASES  OF  THE  ABDOMEN. 


123 


system,  the  sensation  of  hunger  might  no  doubt  be  abolished  without  this  ano- 
rexia proving  inflammation  of  the  stomach.  A sudden  mental  emotion  produces 
the  same  effect,  and  derangement  of  the  nervous  system  sufficiently  explains  it. 
Be  this  as  it  may,  this  group  of  inflammatory  symptoms  was  combated  by  a 
general  bleeding.  Three  days  passed  on  without  any  improvement  taking 
place.  At  the  end  of  this  time  slight  diarrhoea  set  in  ; then  it  was  towards  the 
thoracic  organs  that  a more  active  congestion  evinced  a tendency  to  be  formed, 
and  at  the  same  time  some  petechiae  appeared.  Leeches  were  applied  to  the 
anus  ; the  symptoms  of  pulmonary  congestion  disappeared,  but  the  purging 
increased,  and  the  tongue  became  red.  A second  application  of  leeches  was 
prescribed.  The  next  day  the  scene  is  changed.  It  was  the  nervous  symp- 
toms principally  which  predominated,  and  the  tongue  resumed  a natural  appear- 
ance, which  it  retained  to  the  termination  of  the  disease.  But  this  return  of 
the  tongue  to  its  natural  state  did  not  prevent  the  disease  from  becoming  worse 
and  worse.  This  rapid  succession  of  symptoms,  and  more  particularly  this 
singular  mixture  of  excitement  and  debility,  are  very  remarkable.  The  nervous 
symptoms  improved  after  the  application  of  blisters  to  the  legs,  but  these  symp- 
toms soon  reappeared  with  more  intensity,  and  the  ataxo-adynamic  state  be- 
came more  and  more  marked.  Combated  by  tonic  treatment,  the  symptoms 
which  characterise  this  state  disappeared  whilst  the  quinquina  was  administered, 
and  at  the  same  time  also  the  purging  ceased. 

Case  70. — At  the  commencement  anorexia  and  diarrhoea;  stupor;  delirium;  tongue  red; 
petechiae ; application  of  leeches;  improvement — Reappearance  of  the  ataxo-adynamic 
symptoms  in  consequence  of  an  error  in  diet;  gangrene  of  the  blisters;  abscess;  continu- 
ance of  the  diarrhoea  after  the  cessation  of  the  fever — Tonics. 

A man,  thirty-four  years  of  age,  of  a strong  constitution,  residing  in  Paris  for 
the  last  year,  fell  ill,  and  complained  of  entire  loss  of  appetite  on  the  18th  of 
April.  For  this  he  could  not  assign  a cause.  On  the  following  day  the  illness 
increased  ; a feeling  of  lassitude  came  on,  and  slight  purging. 

On  the  25th  of  April,  the  day  he  entered  the  Charite,  his  face,  which  was  much 
injected,  presented  at  the  samo  timo  an  air  of  stupor  which  indicated  a serious 
disease.  During  the  night  there  had  been  some  delirium  ; there  was  some 
petechiae  on  the  chest,  and  in  smaller  numbers  on  the  abdomen;  the  tongue  was 
red;  two  liquid  stools  had  taken  place  during  the  last  twenty-four  hours;  the 
abdomen  was  soft  and  free  from  pain;  fever  was  principally  indicated  by  the 
burning  heat  of  skin  ; pulse  but  moderately  frequent. 

There  was  to  combat  in  this  patient — first,  the  tendency  of  blood  towards  the 
head,  which  was  indicated  by  the  delirium  at  night;  the  intense  redness  of  the 
eyes  and  face ; and  the  commencing  stupor.  (Twenty-four  leeches  were  applied 
to  the  neck.) 

2dly,  intestinal  irritation,  indicated  particularly  by  the  character  of  the  alvine 
dejections.  (Twelve  leeches  to  the  anus.) 

This  double  abstraction  of  blood  should  also  moderate  the  fever,  whatever 
might  be  the  cause  of  it.  The  leeches  applied  to  the  neck  bled  very  profusely ; 
still  the  patient  was  delirious  in  the  evening  and  all  the  night.  On  the  morning 
of  the  26th,  his  intellects  were  clear;  the  expression  of  the  countenance  was 
more  natural ; the  redness  of  the  tongue  was  gone  ; the  petechiae  had  in  a great 
measure  disappeared ; only  one  stool  of  considerable  consistence  had  taken  place ; 
the  fever  was  not  high.  M.  Lerminier  directed  the  application  of  two  sinapisms 
to  the  legs  in  the  evening,  with  the  intent  to  avert  from  the  brain  the  periodical 
irritation  of  which  this  organ  became  the  seat  every  night.  (Demulcent  ptisans.) 
The  delirium  was  accordingly  much  less.  On  the  27th  the  petechiae  were  more 
numerous ; some  increase  of  the  purging  (a  sinapism  in  the  evening) ; no  deli- 
rium. On  the  28th,  the  same  state.  (Broths.) 


124 


ANDRAL’S  MEDICAL  CLINIC. 


Iii  the  evening  of  the  28th  the  patient  procured  a little  food  by  some  means. 
29th,  tongue  red  and  dry,  diarrhoea  increased  ; the  air  of  stupor  had  reappeared, 
the  frequency  of  the  pulse  had  increased,  but  it  was  very  readily  compressed  ; 
the  tendency  to  the  adynamic  state  was  evident.  Though  the  exacerbation  of 
the  inflammatory  state  of  the  digestive  passages,  under  the  influence  of  an  error 
in  regimen,  appeared  to  be  the  cause  of  the  symptoms  becoming  worse,  should 
bloodletting  be  attempted  ? Should  we  not  take  into  account  the  diminution  of 
strength  as  attested  by  the  extreme  weakness  of  the  pulse?  M.  Lerminier  did 
not  think  it  expedient  to  take  any  more  blood  ; he  ordered  two  blisters  to  the  legs. 
On  the  30th,  the  tongue  had  become  moist  again.  The  first  three  days  in  May, 
it  became  dry  again  ; the  prostration  of  strength  went  on  increasing  ; the  alvine 
evacuations  were  involuntary  ; the  pulse  did  not  rise  ; the  petechial  spots  con- 
tinued ; the  intellects  were  intact.  (Barley  ptisan,  sinapisms,  broths,  a small 
quantity  of  wine.) 

On  the  4th,  aqueous  infusion  of  quinquina  sweetened  with  syrup  of  quince. 
From  the  5th  to  the  12th  this  medicine  was  continued.  During  this  time  the 
strength  of  the  patient  was  observed  to  improve,  the  purging  was  moderated,  the 
features  began  to  recover  their  normal  state,  the  tongue  and  lips  became  moist 
and  red,  the  tongue  began  to  throw  off  the  black  incrustation  with  which  it 
was  covered,  the  pulse  began  to  improve,  and  the  petechiae  to  disappear.  On 
the  17th,  the  patient  had  scarcely  any  fever  ; he  had  had  but  one  stool  during 
the  last  twenty-four  hours;  but  the  blistered  surfaces  had  a greyish  aspect,  and 
evinced  a tendency  to  become  gangrenous.  They  were  covered  with  quin- 
quina powder.  This  bark  was  continued  internally  till  the  22d.  The  blisters 
soon  assumed  a red  appearance  and  became  dry.  The  patient  was  going  on 
very  well  in  other  respects.  At  this  time  three  small  abscesses  existed  at  the 
union  of  the  right  buttock  and  the  thigh  ; they  were  opened,  and  a considerable 
quantity  of  good  pus  was  discharged  from  them.  They  were  cicatrised  on  the 
28th.  Still  the  pulse  retained  a slight  frequency  which  seemed  to  survive  all 
local  lesion.  On  the  night  of  the  28th  a very  profuse  sweat  came  on.  Up  to 
this  period  the  pulse  had  continued  remarkably  dry.  On  the  30th  there  was  no 
sweat,  but  slight  diarrhoea  came  on,  which  continued  up  to  the  3d  of  June.  The 
patient  continued  to  improve,  and  left  the  hospital  on  the  5th  of  June. 

The  patient  in  this  case  was  treated  according  to  the  antiphlogistic  method, 
as  long  as  the  general  signs  of  excitement  continued.  This  method  was  at  first 
successful.  A relapse  occurred  in  consequence  of  an  error  in  regimen.  Blisters 
then  seemed  to  effect  a useful  revulsion  on  the  intestinal  tube;  but  they  did  not 
prevent  the  debility  from  increasing.  As  soon  as  the  latter  became  the  prevail- 
ing symptom,  the  quinquina  was  given.  At  the  time  we  began  to  give  the  Peru- 
vian bark,  the  patient  was  in  a very  alarming  state,  and  during  its  use  all  the 
bad  symptoms  disappeared.  The  surface  of  the  blisters  seemed  on  the  point  of 
becoming  gangrenous,  when  a tonic  treatment  was  tried  ; the  dark  colour  which 
caused  us  to  apprehend  it  had  disappeared  during  the  internal  and  external 
employment  of  the  quinquina.  We  have,  however,  so  often  seen  this  kind  of 
treatment  either  fail,  or  prove  injurious  under  similar  circumstances,  that  we  shall 
content  ourselves,  in  this  case  as  in  several  others,  to  look  upon  the  employment 
of  the  tonic  treatment,  and  the  improvement  of  the  symptoms  as  coincident, 
without  establishing  between  these  two  facts  the  relation  of  cause  and  effect. 
Observe,  however,  how  much  has  been  published  concerning  the  happy  results 
of  the  employment  of  quinquina  in  typhoid  fevers.  If  it  were  sufficient  to  count 
facts  in  order  to  decide  a question,  we  should  be  but  little  embarrassed,  for  we 
might  find  at  least  as  many  of  these  facts  in  favour  of  the  employment  of  quin- 
quina as  in  favour  of  bloodletting.  Read  De  Haen,  see  how  many  facts  he  re- 
lates, in  which  the  petechiae,  prostration,  involuntary  stools,  delirium,  convul- 


DISEASES  OF  THE  ABDOMEN.  125 

sive  movements,  subsultus  tendinum,  irregularity  of  the  pulse,  burning  heat  of 
skin,  &e.,  disappear  under  the  influence  of  this  medicine. 

Independently  of  the  treatment,  this  case  may  afford  instruction  by  reason  of 
some  of  the  phenomena  presented  by  the  disease.  During  the  entire  course  of 
the  disease,  the  skin  continued  very  dry.  No  phenomenon  which  could  be  called 
critical  had  taken  place,  when  convalescence  already  seemed  to  commence.  Still 
the  pulse  retained  a frequency,  which  seemed  to  indicate  that  no  crisis  had  as 
yet  come.  Then  several  abscesses  appeared,  which  the  ancients  would  not  have 
hesitated  to  consider  critical.  They  would  have  found  in  this  case  the  confirma- 
tion of  an  opinion  of  Hippocrates,  who  considered  abscesses  forming  towards 
the  termination  of  acute  diseases  as  very  favourable,  particularly  when  seated  in 
the  lower  extremities. 

The  ancients  also  said  that  abscesses  most  frequently  did  not  appear  till  after 
other  crises,  when  the  latter  had  been  insufficient  or  incomplete.  Here,  on  the 
contrary,  it  was  the  first  phenomenon  which  appeared  ; the  rapidity  of  their  deve- 
lopment and  of  their  termination  would  have  been  considered  as  the  sign  of  a 
favourable  crisis. 

Scarcely  were  these  abscesses  closed,  when  the  skin  became  covered  for  the 
first  time  with  a profuse  sweat,  and  it  was  only  after  the  new  crisis  that  the  pulse 
entirely  lost  its  frequency.  This  sweat  appeared  towards  the  fortieth  day. 
This  fact  would  be  calculated  to  confirm  Huxham’s  assertion,  who  stated  that 
he  had  never  seen  any  typhoid  fever  accompanied  by  a perfect  crisis,  before  a 
sweat  more  or  less  profuse  had  supervened.  But  in  how  many  other  cases 
have  we  not  ascertained  a favourable  and  complete  termination  of  these  diseases 
without  any  sweat  having  appeared?  The  physicians  of  preceding  ages  would 
have  considered  as  a third  critical  movement,  the  diarrhoea  which  appeared  on 
the  30th  of  May,  two  days  after  the  appearance  of  the  sweat.  Guided  by  the 
aggregate  of  the  favourable  circumstances  which  preceded,  accompanied,  and 
followed  the  establishment  of  this  diarrhoea,  they  would  unquestionably  have 
made  reference  to  it.  The  first  of  the  cases  placed  by  Raederer  and  Wagler 
after  their  general  history  of  mucous  fever,  presents  to  us  the  well  marked 
example  of  a continued  fever,  which  ceased  on  the  14th  day,  at  the  same  time 
that  a purging  set  in  ; from  this  time  the  febrile  disturbance  no  longer  appeared. 

The  petechiae  which  existed  at  the  time  of  the  patient’s  admission,  disap- 
peared in  a great  measure  after  the  abstraction  of  blood.  The  disappearance  of 
those  spots  coincided  with  a perceptible  amendment  in  the  general  and  local 
symptoms  ; and  when  on  the  next  day  they  again  appeared,  their  reappearance 
did  not  seem  to  exercise  the  least  influence. 

Case  71. — Residence  in  Paris,  of  a recent  date — At  the  commencement,  pain  in  the  epigas- 
trium ; loss  of  appetite  ; then  adynamic  symptoms  ; tongue  black  ; petechiae  ; last  degree  of 
prostration,  &c. — Successive  employment  of  bloodletting,  blisters,  camphor,  quinquina,  and 
calomel — Amendment  slow. 

A young  man,  20  years  of  age,  of  a delicate  constitution,  and  scarcely  pre- 
senting any  signs  of  puberty,  had  been  residing  in  Paris  for  about  a year. 
Since  that  period  he  had  been  in  great  want,  and  was  badly  fed.  Still  his 
health  was  tolerably  good  till  the  beginning  of  November.  He  then  began  to 
feel  an  habitual  pain  in  the  epigastrium  ; his  appetite  was  lessened,  his  strength 
wa3  evidently  sinking.  He  continued  however  to  remain  at  the  corner  of  the 
streets,  exposed  to  all  the  inclemencies  of  the  weather.  It  was  only  the  last 
two  or  three  days  he  was  obliged  to  keep  his  bed  ; he  entered  the  C barite  on 
the  29th  of  November,  and  on  the  30th  presented  the  following  state  : — 

Face  emaciated,  yellowish,  expressive  of  dejection  and  distress  ; eyes  heavy  ; 
evident  commencement  of  prostration  ; answers  distinct  but  slow.  Some  sub- 
sultus tendinum  of  the  left  hand  ; tongue  already  dry  and  brownish  at  the  centre, 
II* 


126 


ANDRAL’S  MEDICAL  CLINIC. 


but  moist  and  of  a cherry-red  colour  at  the  edges  and  apex ; intense  thirst,  sen- 
sation of  heat  in  the  mouth  ; slight  pain  in  the  epigastrium  on  pressure  ; the 
rest  of  the  abdomen  soft,  and  free  from  pain  ; diarrhoea  for  the  last  two  days 
only  (five  or  six  liquid  stools  in  the  twenty-four  hours);  pulse  frequent  and 
weak  ; skin  hot  and  remarkably  dry  ; breathing  hurried,  cough  frequent  and 
dry.  This  patient  was  far  advanced  in  an  adynamic  state  ; the  dulness  of  his 
eyes,  his  eyelids  weighed  down,  his  countenance  expressive  of  distress,  the 
difficulty  of  his  movements,  and  above  all  the  debilitating  circumstances  which 
had  preceded  his  present  state,  all  seemed  to  point  out  that  the  indication  was 
to  raise  his  exhausted  strength  ; but  there  existed  at  the  same  time  a twofold 
irritation  of  the  lungs  and  alimentary  canal.  Should  this  be  first  combated  ? 
Might  it  not  be  apprehended,  that,  by  neglecting  it,  it  might  concentrate  the 
remainder  of  the  patient’s  strength  on  the  inflamed  organs,  and  thus  increase 
the  general  debility  ? But  admitting  the  necessity  of  first  combating  this  irri- 
tation, should  we  only  endeavour  to  remove  it  by  derivatives  and  irritating  re- 
vulsives ? had  any  effort  been  made  to  attack  it  directly  by  bloodletting  ? M. 
Lerminier  determined  to  try  what  effect  would  be  produced  by  the  latter  means. 
Twenty  leeches  were  applied  to  the  anus  : they  bled  profusely  ; no  perceptible 
change  came  on  in  the  course  of  the  day.  In  the  night  the  patient  became  de- 
lirious. On  the  morning  of  December  the  1st,  the  intellect  was  sound  ; but 
the  air  of  stupor  was  still  more  marked  than  on  the  day  before.  The  abdomen 
was  covered  with  numerous  red  spots,  of  a pale  red  colour.  The  state  of  the 
tongue  was  not  changed ; he  had  had  only  one  stool.  The  pulse  was  very 
weak,  regular,  and  112  ; the  respiratory  movements  were  twenty-nine  in  the 
minute.  Cough  still  continued.  Subsultus  increased. 

The  derivative  bleeding  from  the  anus  seemed  to  have  diminished  the  inten- 
sity of  the  inflammatory  symptoms  of  the  chest  and  abdomen  ; but  the  debility 
of  the  patient  went  on  increasing.  The  delirium  and  subsultus  indicated  at  the 
same  time  an  exaltation,  or,  more  properly  speaking,  a perversion  of  the  func- 
tions of  the,  nervous  system.  However,  if  these  different  symptoms,  as  also 
the  prostration,  had  been  the  result  of  inflammation  of  the  digestive  passages, 
should  not  the  evident  diminution  of  the  latter  have  been  accompanied  with  a 
general  improvement  in  the  state  of  the  patient?  Now  the  patient  was  evi- 
dently not  so  well  as  the  day  before.  Two  blisters  were  applied  to  the  legs. 
A camomile  lavement  was  given,  with  the  addition  of  twelve  grains  of  camphor. 
Nothing  was  directed  to  be  taken  internally  but  barley  ptisan,  acidulated  with 
tartaric  syrup.  The  night  was  more  tranquil  than  that  preceding  it. 

Dec.  2.  The  air  of  stupor  was  diminished  ; the  tongue  was  moist  and  red  ; 
the  abdomen  soft.  The  lavement  was  not  returned.  The  subsultus  and  pete- 
chiae  were  increased.  Some  petechiae  on  the  chest.  There  was  an  evident 
improvement,  which  might  fairly  be  attributed  to  the  plan  of  treatment.  The 
patient  took  in  the  course  of  the  day  a second  camomile  lavement,  with  the 
addition  of  twenty-four  grains  of  camphor.  In  the  evening  his  legs  were 
covered  with  sinapisms  (barley  ptisan  sweetened).  At  this  time  the  lavement 
was  returned  a little  time  after  it  had  been  taken.  The  patient  raved  a great  part 
of  the  night.  On  the  3d,  though  his  answers  were  distinct  and  precise,  still  he 
was  heard  to  speak  aloud  from  time  to  time,  and  rather  incoherently.  The 
adynamic  state  went  on  increasing;  the  longue  again  became  brown  ; skin  still 
dry  (mineral  lemonade,  two  more  blisters  to  the  thighs).  At  three  in  the  after- 
noon a general  and  profuse  sweat  took  place.  Still  the  state  of  the  patient,  far 
from  being  improved,  appeared  worse  on  the  next  day  than  ever.  The  coun- 
tenance was  cadaverous,  tongue  black  and  dry,  as  also  the  teeth  and  lips  ; the 
abdomen  became  swollen  ; no  purging.  The  breathing  was  again  hurried  : the 
pulse  could  scarcely  be  felt ; the  ideas  became  disturbed  at  intervals  (aqueous 
infusion  of  quinquina  with  oxymel,  camomile  lavement  with  twelve  grains  of 


DISEASES  OF  THE  ABDOMEN. 


127 


camphor;  six  packets  of  camphor  and  nitre,*  mineral  lemonade,  one  cup  of 
wine).  On  the  5ih  he  was  in  the  same  state  ; the  same  prescription  was  or- 
dered. On  the  6th  he  no  longer  seemed  to  understand  the  questions  proposed 
to  him.  He  pronounced  with  hesitation  some  unintelligible  words.  The 
petechial  spots  continued  ; the  respiration  had  now  become  slower. 

On  the  7th  and  8th  nothing  new  occurred.  The  patient  seemed  to  be  reduced 
to  the  last  stage  of  prostration.  Death  appeared  close  at  hand  (the  same  medi- 
cine continued).  On  the  9th,  twelve  grains  of  calomel  were  given  to  overcome 
the  constipation  ; he  had  one  stool.  To  his  other  drinks  we  added  a decoction 
of  polygala,  sweetened  with  syrup  of  orange-peel.  The  pulse,  which  was 
very  small,  was  extremely  irregular.  From  the  9th  to  the  13th  the  petechiee 
disappeared.  The  strength  seemed  to  rise  a little.  On  the  14th  the  aspect  of 
the  face  was  more  natural,  the  eyes  had  more  expression,  the  intellect  was  not 
so  dull,  articulation  was  easier;  the  tongue,  which  was  moist,  was  brown  only 
at  the  centre  ; he  could  put  it  out  of  his  mouth  with  considerable  facility, 
which  he  could  not  do  on  the  preceding  days.  A slight  purging  existed  (some 
broths  were  now  allowed).  During  the  night  of  the  16th  he  was  extremely 
agitated,  and  some  convulsive  movements  took  place.  From  the  17th  there 
was  a progressive  improvement,  which  was  slow  however;  this  was  accounted 
for  by  the  occurrence  of  a purging,  which  continued  for  a considerable  time, 
and  which  did  not  appear  till  the  time  nature  seemed  commencing  to  proceed 
towards  a cure.  The  aqueous  infusion  of  quinquina  was  continued  till  the  be- 
ginning of  January.  At  this  time  the  countenance  of  the  patient  was  very 
much  improved  ; he  was  gaining  flesh,  and  had  a great  appetite.  He  left  the 
hospital  on  the  15th,  perfectly  recovered. 

Here  is  a case  in  which  a patient,  whose  state  was  almost  desperate  at  the 
time  he  began  to  take  tonics,  was  restored  to  health  according  as  he  took  the 
quinquina,  polygala,  camphor,  wine,  &c.  During  the  employment  of  these 
remedies  we  saw  the  tongue  become  moist,  the  skin  lose  its  burning  heat  and 
dryness,  the  intellect  recover  its  clearness,  the  convulsive  movements  disappear, 
and  the  strength  return.  And  yet  how  very  unfavourable  the  prognosis  was  ! 
The  countenance  was  for  several  days  that  of  a man  in  the  last  agony,  and  ex- 
perience has  proved  that  this  state  of  the  countenance  is  almost  always  fatal. 
We  may  here  say,  with  Hippocrates,  In  acutis  rnorbis  non  omnino  tutse  sunt 
prsedictiones , neque  mortis , neque  sanitatis. 

We  read  in  Grant  ( Researches  on  Fever)  a case  calculated  to  prove  that  cer- 
tain individuals  carry  with  them  a peculiar  disposition  to  adynamic  symptoms, 
from  the  moment  they  become  affected  with  any  disease  whatever,  though  not 
very  violent.  The  subject  of  this  case  is  a young  girl  who,  two  years  after 
having  had  typhoid  fever  with  epistaxis  and  petechiae,  was  inoculated  at  the 
same  time  with  her  brothers  and  sisters.  In  the  latter  the  variola  which  super- 
vened terminated  favourably  and  mildly.  In  the  young  girl,  on  the  contrary, 
the  cuts  in  the  arm  were  observed  to  become  livid,  to  puff  up,  and  exhale  a 
bloody  sanies.  On  the  seventh  day  numerous  petechiae  appeared,  and  there 
were  observed  all  the  symptoms  of  a putrid  fever,  which  complicated  the  variolic 
eruption,  and  interfered  with  its  course.  Is  it  to  be  supposed  that  in  such  a 
case  we  should  have  recourse  to  an  antiphlogistic  mode  of  treatment?  Nothing 
was  more  variable  during  the  entire  course  of  the  disease  than  the  state  of  the 
respiration.  We  found  it  from  one  day  to  another  easy  or  painful,  slow  or 
very  much  hurried.  M.  Lerminier  at  first  apprehended  the  existence  of  inflam- 
mation of  the  pulmonary  parenchyma ; but  these  rapid  alternations  soon  ap- 
peared to  him  entirely  connected  with  the  state  of  the  nervous  system.  This 

* Each  packet  contains  six  grains  of  camphor  and  six  of  nitre.  One  is  given  every  third 
hour. 


128 


ANDRAL’S  MEDICAL  CLINIC. 


was  not  the  only  time  we  observed  a similar  disturbance  of  the  respiration  in 
individuals  affected  with  bad  typhoid  fevers,  and  after  death  we  found  the  lungs 
perfectly  healthy.  In  other  patients,  on  the  contrary,  whose  breathing  had 
always  been  very  easy,  the  post-mortem  examination  discovered  pneumonia  to 
a greater  or  less  extent. 

Is  it  not  also  a very  remarkable  phenomenon,  however  usual  in  other  respects 
— I mean  the  excitement  of  the  nervous  system,  as  attested  by  the  delirium, 
subsultus,  &c.,  whilst  the  other  systems  were  in  a state  of  debility  ? It  is  thus 
that,  in  severe  hemorrhages,  we  see  patients,  though  exhausted  by  the  enor- 
mous loss  of  blood  which  they  have  suffered,  die  often  in  the  midst  of  convul- 
sions more  or  less  violent.  Did  the  camphor  in  this  case  contribute  to  calm 
the  excited  or  perverted  action  of  the  brain  and  its  appendages?  We  may  ob- 
serve that  an  evident  improvement  succeeded  the  administration  of  the  first  cam- 
phor lavement,  which  was  all  retained,  whilst  the  symptoms  partly  reappeared 
after  the  second  lavement,  which  was  partly  returned. 

If  the  physiological  action  of  camphor  is  well  ascertained,  such  unfortunately 
is  not  the  case  with  its  therapeutic  properties.  The  histories  of  poisoning  by 
camphor  in  the  human  species,  and  experiments  made  on  living  animals,  tend 
equally  to  prove  that  this  substance  stimulates  the  brain  very  much,  and  yet  it 
is  often  prescribed  for  the  purpose  of  calming  the  nervous  system.  At  other 
times  it  is,  to  be  sure,  administered  under  the  title  of  a diffusible  stimulant. 
What  contradictions!  Is  camphor  often  effectual  only  in  as  much  as  it  opposes 
one  stimulation  to  another,  by  changing  the  mode  of  action  of  the  nervous  sys- 
tem ; as  several  medicines  called  antipasmodic  seem  to  do  ? Again,  has  cam- 
phor, like  several  other  substances,  a different  action  according  to  its  different 
doses?  If  we  consult  authors  we  shall  find  them  very  little  agreed  among  them- 
selves. Thus  Cullen  tells  us,  that  after  having  administered  camphor  a great 
number  of  times,  he  was  not  yet  certain  whether  this  medicine  was  useful  or 
injurious.  Hoffmann  is  more  positive  ; he  considers  camphor  combined  with 
nitre  as  one  of  the  best  medicines  that  can  be  given  in  all  cases  of  malignant 
fevers.  I am  inclined  to  think  that  it  is  with  camphor  as  with  digitalis.  If  the 
researches  of  a great  number  of  medical  men  with  respect  to  the  therapeutic 
properties  of  these  substances  have  oftentimes  led  to  the  most  opposite  results, 
it  is  because  the  observers  have  not  pointed  out  with  sufficient  precision  under 
what  combination  of  circumstances  they  had  used  them.  Neither  has  sufficient 
regard  been  paid  to  the  differences  which  camphor  must  present  in  its  mode  of 
action  according  to  the  state  of  the  organs,  and  the  temperaments  and  disposi- 
tions of  the  individuals.  We  have  observed,  for  instance,  in  some  persons  pos- 
sessed of  great  nervous  susceptibility,  a peculiar  kind  of  stimulation  made  on 
the  brain  by  camphor.  These  persons,  after  taking  camphor  in  the  form  o 
lavement  in  rather  a moderate  dose  (twenty  to  thirty  grains),  felt  themselves 
suddenly  possessed  of  extraordinary  lightness  ; they  fancied  themselves  going 
to  fly,  according  to  the  phrase  adopted  by  them  all.  This  singular  effect,  of 
which  I myself  have  seen  an  instance  in  a young  Englishman,  lasted  for  some 
hours,  and  gradually  disappeared. 

The  petechiae  in  this  case  were  very  numerous.  They  appeared  before  any 
species  of  stimulant  treatment  had  been  employed.  It  was  not  the  latter  then 
that  produced  them,  as  was  supposed  by  De  Haen. 

Case  72. — Residence  in  Paris,  of  a recent  date — At  first  symptoms  of  what  may  be  called  in- 
flammatory fever;  delirium  after  bloodletting — Subsequently  symptoms  usually  called  bilious  ; 
tartar  emetic  ; on  the  day  after  the  administration  of  the  latter  medicine,  severe  symptoms 
resembling  those  of  an  attack  of  typhoid  fever  ; return  of  this  attack  on  the  following  days  : 
quinquina  at  first  given  as  anti-periodical,  then  as  a tonic. 

A young  man,  eighteen  years  of  age,  of  rather  a delicate  constitution,  light 


DISEASES  OF  THE  ABDOMEN. 


129 


coloured  hair,  and  flaccid  muscle,  always  enjoyed  rather  good  health  ; he  was  a 
resident  in  Paris  for  about  three  months,  and  was  not  subject  to  any  privations. 
May  11th,  without  any  known  cause,  he  felt  on  awaking  a state  of  general  ill- 
ness, and  some  pain  of  head  ; there  was  a bitter  taste  in  his  mouth.  In  the 
course  of  the  day  he  had  some  shivering.  On  the  12th  he  was  confined  to  bed  ; 
13th,  entered  the  Charite  ; and  on  the  14th  he  presented  the  following  state  : 
— face  and  conjunctiva  injected,  skin  halitneuse,  pulse  frequent  and  full,  tongue 
whitish,  red  at  the  apex,  not  much  thirst,  abdomen  soft  and  free  from  pain,  one 
stool  of  good  consistence  in  the  twenty -four  hours.  This  person  presented  a 
group  of  inflammatory  symptoms,  which  called  for  bleeding.  In  localising  the 
disease  one  might  consider  it  gastritis,  and  from  this  derive  all  the  other  symp- 
toms as  so  many  sympathetic  phenomena.  He  was  bled  copiously  ; barley 
ptisan  with  oxymel  was  prescribed.  The  blood  drawn  from  the  vein  united 
into  a large  clot  of  but  little  consistence,  and  greenish  on  its  surface.  During 
the  day  the  state  of  the  patient  continued  nearly  the  same  ; he  had  some  nau- 
sea. In  the  night  his  sleep  was  disturbed  by  the  most  incoherent  dreams ; he 
had  but  one  stool. 

On  the  morning  of  the  15th  the  fever  still  continued,  tongue  not  so  red  (thirty 
leeches  to  the  anus).  In  the  night  the  patient  was  very  much  disturbed,  and 
was  in  a state  bordering  on  delirium.  On  the  16th  he  complained  of  an  intole- 
rably bitter  taste,  he  had  frequent  nausea  and  but  little  thirst ; the  tongue  was 
covered  since  the  day  before  with  a thick  yellowish  coat  ; there  had  been  no 
stool ; the  red  tint  of  the  cheeks  contrasted  with  the  yellowish  tint  of  the  parts 
around  the  alae  nasi,  the  lips,  and  the  conjunctiva  ; the  pulse  was  constantly 
very  pregnant  and  full,  skin  hot  and  dry.  Thus  the  state  of  the  patient  had 
undergone  a perceptible  change  since  the  day  before.  The  decidedly  inflam- 
matory symptoms  of  the  preceding  days  was  now  succeeded  by  that  combina- 
tion of  symptoms  usually  called  bilious.  M.  Lerminier  prescribed  two  grains 
of  tartar  emetic  in  a pint  of  veal  water  ; but  as  the  fever  was  still  high,  he  or- 
dered the  application  of  thirty  leeches  to  the  anus  previous  to  the  emetic  being 
taken. 

The  patient  did  not  vomit,  and  went  but  once  to  stool.  On  the  next  day,  the 
17th,  the  tongue,  divested  of  its  yellowish  coat,  had  resumed  its  red  appearance  ; 
his  state  was  the  same  in  other,  respects  (barley  tisan,  with  oxymel).  In  the 
evening  the  patient,  who  had  passed  the  day  tolerably  well,  was  attacked  with 
violent  shivering  and  great  dyspnoea.  At  eight  o’clock  the  shivering  no  longer 
existed  ; but  the  patient,  devoured  by  a burning  heat,  was  now  in  an  extreme 
state  of  prostration  ; it  was  only  at  intervals  he  answered  questions,  and  at  in- 
tervals he  was  completely  delirious.  The  respiration  was  high  and  hurried, 
the  pulse  small,  concentrated,  and  irregular;  great  subsultus  in  the  fore-arms. 
Thus  the  patient  had  suddenly  passed  from  a state  not  at  all  alarming  to  one 
which  was  considered  as  hopeless  by  those  who  saw  him  in  the  evening. 
However,  on  the  morning  of  the  18th,  we  found  him  not  so  bad.  The  respi- 
ration was  more  free  ; the  strength  was  raised  ; the  intellect  was  again  clear, 
the  subsultus  tendinum  was  less  ; the  pulse,  which  was  regular,  retained  its 
smallness  ; the  countenance  was  still  expressive  of  great  depression,  the  skin 
was  covered  with  a gentle  moisture  ; the  abdomen  was  tympanitic,  no  stool 
had  taken  place  ; the  bladder,  distended  by  an  enormous  quantity  of  urine,  pro- 
jected considerably  above  the  pubis  ; we  were  obliged  to  draw  off*  the  urine  ; a 
blister,  made  with  a mixture  of  liquid  ammonia  and  axunge,  was  applied  to 
each  thigh.  He  was  in  the  same  state  up  to  the  19th,  at  six  in  the  evening. 
Then  there  was  a return  of  the  same  symptoms  as  on  the  17th,  but  with  much 
greater  severity.  At  nine  o’clock  the  patient  seemed  as  if  struck  with  apo- 
plexy ; there  was  total  loss  of  consciousness  ; the  eyelids  remained  depressed 
over  the  eyes  ; when  they  were  raised,  the  globe  of  the  eye,  which  was  fixed 
and  immoveable,  seemed  insensible  to  the  impression  of  light ; the  nostrils  were 


130 


ANDKAL’S  MEDICAL  CLINIC. 


forcibly  dilated  at  each  inspiration,  and  each  expiration  was  accompanied  with 
a passive  dilatation  of  the  cheeks  ; the  tongue,  which  was  perceived  at  the  bot- 
tom of  the  mouth,  appeared  dry  and  brown  at  its  centre  ; the  abdomen  was  very 
tympanitic  ; the  pulse  was  so  frequent  that  it  could  not  be  counted.  On  the 
next  day,  the  20th,  there  was  an  amendment  similar  to  that  which  we  had 
already  observed  on  the  18th,  the  patient  had  recovered  his  consciousness,  but 
he  still  retained  a very  remarkable  air  of  stupor;  as  on  the  18th,  the  skin  was 
moist.  This  periodical  return  of  the  same  symptoms  under  the  tertian  type, 
the  shivering  which  ushered  in  their  invasion,  the  moist  state  of  the  skin  which 
became  manifest  according  as  the  severe  symptoms  subsided,  might  incline  one 
to  suspect  the  existence  of  a pernicious  remittent  fever.  The  second  attack  had 
been  more  violent  than  the  first;  there  was  some  reason  to  apprehend  that  the 
third  would  prove  fatal. 

On  the  21st,  the  day  on  which  the  third  accession  should  show  itself,  twelve 
grains  of  sulphate  of  quina  were  given  by  the  mouth,  ten  hours  before  its  ex- 
pected invasion,  and  one  ounce  of  powdered  quinquina,  in  the  form  of  lavement. 
In  the  evening  the  paroxysm  did  not  return.  However,  the  patient  was  far 
from  being  out  of  danger;  the  adynamic  state  was  more  and  more  marked;  the 
black  colour  of  the  tongue  had  progressed;  considerable  purging  set  in;  the 
quinquina  was  still  continued  in  the  form  of  lavement,  in  the  dose  of  half  an 
ounce  every  day  up  to  the  25th,  with  the  view  of  preventing  any  return  of  the 
fit.  Since  the  20th  the  surface  of  the  blisters  had  taken  on  a brownish  tint,  and 
on  the  23d  they  were  covered  by  a large  eschar.  The  paralysis  of  the  bladder 
still  continued,  and  the  urine  was  drawn  off  by  the  catheter.  On  the  25th,  the 
tongue,  lips,  and  teeth  were  covered  by  a thick  black  crust;  the  abdomen  was 
very  much  distended  ; five  or  six  liquid  stools  were  passed  in  bed.  There  was  at 
the  same  time  an  acrid  heat  of  skin,  great  frequency  and  smallness  of  the  pulse, 
which  was  easily  compressed  ; a well  marked  air  of  stupor  ; great  dulness  of  the 
intellectual  faculties  ; total  loss  of  memory  ; extreme  muscular  debility  ; eschars 
on  the  blistered  surfaces,  on  the  sacrum,  and  on  the  great  trochanter  of  the  left 
side;  paralysis  of  the  bladder.  We  no  longer  apprehended  a return  of  the 
paroxysm.  In  this  state  of  things  should  our  attention  be  directed  only  to  the 
palpable  inflammation  of  the  alimentary  canal,  and  should  we  order  merely 
demulcent  medicines  ? Should  we  rather  consider  the  general  state  of  the 
strength,  the  real  absence  of  which  seemed  to  be  indicated  by  several  of  the 
symptoms?  Should  we  admit  with  Brown,  that  the  period  of  general  excite- 
ment had  been  succeeded  by  a period  of  collapse;  or  say  with  M.  Broussais 
that  the  strength  was  not  really  absent,  but  that  it  was  concentrated  on  the 
digestive  tube  ? Even  admitting  this  latter  opinion,  would  we  have  been  war- 
ranted in  rejecting  tonics  and  excitants  ? Are  there  not  several  cases  of  external 
inflammations,  where  tonics  are  employed  with  advantage,  as  well  internally, 
as  on  the  inflamed  surfaces  themselves?  M.  Lerminier  prescribed  a camomile 
lavement  with  the  addition  of  five  drops  of  essential  oil  of  juniper ; citric  lemon- 
ade for  his  drink  ; some  broths,  a pint  of  decoction  of  polygala  ; another  pint 
of  decoction  of  two  drachms  of  angelica  root,  with  the  addition  of  two  ounces 
of  syrup  of  violet.  It  is  known  how  much  Hildenbrand  cried  up  the  bene- 
ficial effects  of  angelica  root  in  typhoid  fevers ; he  preferred  it  as  less  expen- 
sive, and  at  the  same  time  as  more  effectual  than  contrayerva  and  seneka  root. 
Embrocations  of  camphorated  oil  of  camomile  were  applied  over  the  abdomen  ; 
twenty-four  hours  after  this  treatment  was  commenced  there  was  a most  evident 
improvement  in  every  respect ; on  the  27th,  the  aqueous  infusion  of  quinquina 
was  substituted  for  the  decoction  of  polygala,  and  mineral  for  citric  lemonade. 
From  the  28th  of  May  to  the  Gth  of  June,  a rapid  improvement  took  place  in  all  the 
symptoms.  During  all  this  time,  however,  there  was  no  sweat,  nor  any  phenome- 
non which  could  be  considered  critical.  On  the  6th  of  June  every  thing  promised 
speedy  restoration,  except  the  ulcer  on  the  great  trochanter,  which  was  every  day 


DISEASES  OF  THE  ABDOMEN. 


131 


enlarging  ; the  profuse  suppuration  from  it  prevented  the  patient  from  recovering 
strength.  The  aqueous  infusion  of  quinquina  was  replaced  by  six  ounces  of 
quinquina  wine.  Innumerable  cases  attest  the  beneficial  effects  of  this  sub- 
stance in  all  cases  of  profuse  suppuration,  without  much  general  reaction.  De 
Haen  in  particular  has  noticed  the  advantages  of  it  (Hat.  med.,  pars  undecima , 
caput  primum).  The  quinquina  wine  was  continued  in  the  dose  of  from  six 
to  eight  ounces  every  day  during  the  month  of  June  and  commencement  of  July. 
The  ulcerations  ceased  to  extend,  all  febrile  symptoms  gradually  disappeared, 
and  the  suppurations  from  the  ulcer  on  the  great  trochanter  being  very  incon- 
siderable, the  quinquina  wine  was  suspended.  On  the  night  of  the  15th  of  July, 
from  eight  to  ten  varioloid  pustules  appeared  on  the  buttocks.  On  the  next 
day  some  were  observed  on  the  arms  and  face.  Having  been  red  and  conical 
at  first,  they  were  already  white  about  thirty  hours  after  their  appearance  ; four 
or  five  of  them  were  depressed  at  their  centre.  Some  of  these  were  remarked 
to  be  confluent  in  the  lumbar  region  ; at  the  end  of  six  days  they  were  all  dried. 
The  eruption  was  not  accompanied  by  any  febrile  disturbance  ; it  resembled 
varicella  very  much.  The  patient  bore  the  marks  of  having  been  vaccinated. 
During  the  last  fifteen  days  of  July  the  feet  became  (Edematous.  This  passive 
infiltration  was  combated  by  the  bitter  diuretic  wine  of  the  Charite,  and  disap- 
peared according  as  the  strength  returned.  He  went  out  on  the  6th  of  August. 

We  have  endeavoured  to  point  out,  in  the  course  of  this  case,  the  circumstances 
which  rendered  it  remarkable.  We  saw  that  the  inflammatory  symptoms  which 
existed  at  the  commencement  were  met  by  repeated  and  copious  bleedings;  that 
at  a later  period  an  emetic  was  administered,  which  produced  no  evacuation;  and 
on  the  following  day  an  exacerbation  showed  itself  for  the  first  time,  which  gave 
to  the  disease  the  character  of  a pernicious  remittent  fever.  The  second  exacer- 
bation was  still  more  alarming  ; the  quinquina  was  then  given  with  success.  I 
shall  not  here  inquire  how  the  good  effects  of  the  quinquina  in  this  case  can  be 
explained;  I merely  state  the  fact,  remarking  that  innumerable  instances  of 
analogous  cases  are  to  be  found  in  books.  Would  the  same  success  have  been 
obtained  if  gastro  intestinal  irritation  had  played  the  principal  part  in  the  group 
of  frightful  phenomena  which  characterised  the  attack  ? The  onset  of  the  dis- 
ease was  probably  in  this  irritation,  but  certainly  the  entire  disease  did  not  re- 
side in  it.  When  there  no  longer  remained  anything  but  the  symptoms  of  a 
most  severe  adynamic  fever,  it  was  still  a highly  tonic  treatment  that  was 
opposed  to  these  symptoms  ; during  this  treatment,  the  tongue,  which  was 
dry  and  black,  soon  returned  to  its  natural  state.  When  profuse  suppuration 
was  exhausting  the  patient,  it  was  by  means  of  quinquina,  given  in  large  doses, 
that  the  strength  was  kept  up.  We  should  here  remark  the  varioloid  eruption 
and  the  oedema,  which  came  on  during  convalescence:  this  oedema,  the  result 
of  general  debility,  disappeared  as  the  strength  was  re-established. 


CHAPTER  III. 

RECAPITULATION. (*) 

ARTICLE  II. 

ETIOLOGY. 

Are  there  certain  causes  which  may  be  considered,  with  some  reason,  as 
having  produced  the  diseases  of  which  the  preceding  cases  afford  instances  ? 

* This  recapitulation  more  particularly  concerns  our  cases  of  follicular  enteritis. 


132 


ANDRAL’S  MEDICAL  CLINIC. 


Among  the  individuals  who  form  the  subjects  of  our  cases,  several  had  suf- 
fered great  mental  distress  ; others  had  been  exposed,  for  a longer  or  shorter 
time,  to  all  the  hardships  of  want;  being  deprived  of  work,  they  had  had  but 
an  unwholesome  or  insufficient  food  to  live  on:  — some  were  distressed  with 
labour  ; they  had  borne  up  against  want  of  sleep  for  several  nights  ; others  had 
been  guilty  of  frequent  deviations  from  regular  regimen,  or  had  indulged  in 
different  species  of  excess  ; but  in  the  greater  number  none  of  these  influ- 
ences had  acted,  — they  had  been  always  well  fed;  they  had  always  worked 
without  being  fatigued,  and  they  had  never  committed  any  excess.  The  re- 
sults at  which  we  arrived  on  this  head  agree  with  those  obtained  by  M.  Louis. 
H e cites  but  a small  number  of  cases  in  which  bad  diet  was  one  of  the  circum- 
stances which  preceded  the  development  of  the  disease.  In  some  others  ex- 
cessive fatigue  and  mental  distress  had  acted,  but  in  the  majority  nothing 
proves  at  least  that  these  different  influences  performed  a part  in  the  production 
of  fever. 

What  we  say  of  patients  in  the  hospitals,  we  might  also  say  of  other  classes 
of  society.  I shall  take  for  instance  our  young  medical  students.  Miasms, 
arising  from  the  dissection-room,  have  been  looked  on  as  one  of  the  causes 
which  render  typhoid  fever  so  common  in  them  ; yet  in  a very  considerable 
number  of  them  I may  assert  that  the  disease  manifests  itself  before  they  have 
frequented  the  dissecting-room.  Bad  diet  and  irregular  habits  have  also  been 
advanced  as  causes  of  sickness  in  these  persons,  and  yeti  have  very  often  seen 
young  persons  affected  who  were  well  fed,  and  whose  conduct  had  been  very 
regular. 

There  is  another  circumstance,  much  more  general,  which  may  be  observed 
in  our  cases,  as  well  as  in  those  of  MM.  Petit  and  Serres,  Bouillaud  and  Louis, 
namely,  recent  arrival  in  Paris.  Among  the  individuals  who  form  the  subjects 
of  the  preceding  cases  there  are  several  who  had  been  residing  in  Paris  only  for 
some  weeks  or  months  at  the  time  they  became  sick.  In  general  it  is  not  atthe 
commencement  of  persons’  residing  in  Paris  that  the  health  becomes  deranged  ; 
it  is  more  frequently  after  a residence  of  from  six  to  fifteen  months.  It  is  about 
this  period  that  we  have  most  commonly  seen  students  in  medicine  or  law  at- 
tacked, as  also  young  mechanics,  who  come  to  seek  for  admission  into  the  several 
hospitals. 

Yet  whilst  we  admit  that  persons  who  have  but  recently  arrived  in  Paris  are 
more  exposed  than  others  to  be  attacked  with  the  disease  now  in  question,  we 
do  not  intend  to  infer  from  this  that  it  attacks  exclusively  persons  of  this  class. 
We  have  cited  a considerable  number  of  cases  of  persons  who  had  been  residing 
in  Paris  for  a great  number  of  years,  and  who  presented  on  the  one  hand  the 
different  symptoms  of  typhus  fever,  and  on  the  other  hand  the  particular  lesion 
of  the  intestinal  follicles.  During  the  summer  of  1829  we  saw,  at  the  Central 
Bureau,  a considerable  number  of  individuals  who  presented  all  the  symptoms 
of  typhoid  fever  in  different  degrees  of  severity,  and  one-third  at  least  of  these 
persons  had  been  residing  in  Paris  for  several  years.  We  have  seen  this  same 
disease  attack  medical  students  who  had  been  living  in  Paris  for  five  or  six 
years. 

Is  typhoid  fever,  when  once  developed,  capable,  of  being  propagated  by  con- 
tagion? In  latter  times  Dr.  Bretonneau,  M.  Gendrin,  and  some  other  medical 
men,  have  maintained  that  dothinenterite  was  a very  contagious  disease  : we 
do  not  deny  the  facts  cited  by  these  writers  ; but  what  we  confidently  assert  is, 
that  in  Paris,  either  in  the  hospitals  or  out  of  them,  we  never  recognised  in  this 
disease  the  slightest  appearance  of  a contagious  character.  In  the  hospitals  we 
do  not  see  it  transmitted  from  the  individual  who  brings  it  from  without  to  those 
who  are  lying  in  the  beds  next  his  own  ; neither  do  we  see  that  the  patients 
who  lie  in  the  bed  previously  occupied  by  a person  who  has  either  recovered 


DISEASES  OF  THE  ABDOMEN. 


133 


from,  or  has  died  of  a dothinenterite,  are  attacked  by  it.  Neither  are  the  phy- 
sicians or  medical  students  who  come  there  attacked  with  it,  more  particularly 
those  who  have  had  to  come  in  contact  with  patients  labouring  under  the  dis- 
ease. Out  of  the  hospitals  what  circumstances  are  more  favourable  to  conta- 
gion than  those  generally  found  combined  in  the  case  of  medical  students  who 
attend  their  companions  when  affected  with  typhoid  fever  ? Shut  up  in  a room, 
which  in  general  is  very  small,  they  pay  them  the  most  assiduous  and  de- 
voted attention  night  and  day  ; if  the  affection  were  contagious,  almost  all  of 
them  would  contract  it,  and  yet  we  do  not  remember  to  have  seen  the  disease 
even  once  arise  in  this  way  in  a healthy  individual.  We  have  frequently  in- 
quired whether  the  bed  or  room  occupied  by  a patient  affected  at  the  time  had 
been  recently  occupied  by  others  who  had  also  had  dothinenterite,  and  we 
found  that  this  occurred  but  very  rarely ; so  that  we  were  then  at  liberty  to 
suppose,  that  if  two  individuals  attacked  with  one  and  the  same  species  of  dis- 
ease had  succeeded  each  other  in  one  and  the  same  place,  it  was  nothing  but 
mere  chance. 

Persons  of  the  most  opposite  constitutions  are  equally  affected  by  the  disease 
in  question.  It  would  be  a great  mistake  to  suppose  that  it  attacks,  in  prefer- 
ence, persons  of  a delicate  constitution,  whose  blood  is  impoverished,  whose 
muscular  system  is  but  badly  developed,  and  in  whom  the  lymphatic  tempera- 
ment seems  to  predominate.  Far  from  it.  The  disease  appears  probably 
more  generally  in  persons  who  are  of  a florid  complexion,  whose  muscular 
system  is  well  developed,  and  appears  to  indicate  considerable  strength.  It  is 
frequently  in  such  persons  that,  after  a few  days1  illness,  an  adynamic  state 
is  seen  to  supervene,  which  does  not  appear  to  be  always  the  result  of  mere 
oppression  of  the  strength,  so  that  it  must  not  be  supposed  that  what  is  called 
force  of  vital  resistance  is  always  accurately  indicated  by  the  state  of  the  mus- 
cular system  ; it  is  represented  much  more  by  the  activity  of  the  nervous 
system  ; and  this  activity  is  very  frequently  in  the  inverse  ratio  of  the  apparent 
energy  of  the  locomotive  system. 

In  this  respect  the  observations  made  by  MM.  Bouillaud  and  Louis  are  en- 
tirely confirmatory  of  our  own.  Among  the  persons  whose  cases  we  have 
given  there  are  several  who  presented  all  the  traits  of  what  is  called  the  sangui- 
neous temperament ; several  had  a brown  skin,  and  the  appearance  of  great 
muscular  strength  ; they  seemed  to  have  considerable  embonpoint,  and  their 
nutrition  did  not  appear  to  have  at  all  suffered. 

All  ages  are  not  equally  exposed  to  present  the  different  groups  of  symptoms 
which  characterise  continued  fevers.  The  result  of  our  own  observation,  as 
well  as  that  of  other  authors,  is,  that  they  are  most  common  from  the  age  of 
twenty  to  that  of  thirty.  From  thirty-five  to  old  age  they  become  more  and 
more  rare  : then,  after  the  age  of  seventy,  we  find  adynamic  fever  to  appear 
again.  It  is  in  the  midst  of  the  symptoms  which  characterise  it  that  a consider- 
able number  of  old  persons  die,  those  particularly  who,  till  then,  had  enjoyed 
good  health,  and  who  seemed  to  have  worn  out  their  vital  energy  by  little  and 
little,  without  there  having  been  any  deep-seated  lesion  of  any  organ  in  them. 

Old  persons,  then,  as  well  as  young,  present  rather  frequent  instances  of  ady- 
namic fever.  But  in  them  the  organic  lesions,  of  which  this  fever  is  either  the 
effect  or  the  complication,  are  not  always  similar  to  those  observed  at  a less  ad- 
vanced period  of  life.  Thus,  in  young  persons,  out  of  ten  cases  of  what  is 
called  adynamic  fever,  there  are  nine  at  least  in  which  the  principal  lesion  found 
in  the  dead  body  is  a dothinenterite.  In  old  persons,  on  the  contrary,  dothin- 
enterite is  uncommon  ; but,  in  its  absence,  symptoms  exactly  similar  to  those 
which  it  produced  in  youth  appear  with  the  greatest  facility  in  consequence  of 
any  other  lesion,  whether  of  pneumonia  or  simple  erysipelas,  or  a slight  phleg- 
mon, or  disease  of  the  urinary  .passages,  &c.  Their  tongue  becomes  dry  and 


134 


ANDRAL’S  MEDICAL  CLINIC. 


black,  without  there  being  in  them  any  intestinal  lesion  appreciable  after  death. 
Here,  then,  is  a case  where  the  symptomatic  form  of  a disease  remains  the 
same,  though  there  is  no  longer  any  identity  in  its  anatomical  form. 


ARTICLE  II. 

OF  THE  STATE  OF  THE  DIFFERENT  ORGANS  AFTER  DEATH  AND 

DURING  LIFE. 

DIGESTIVE  TUBE. 

First — Lesions  found  after  Death  in  the  Digestive  Tube. 

We  have  to  examine  these  lesions  with  respect  to  their  constancy,  their  fre- 
quency, their  seat,  their  nature,  their  intensity,  and,  lastly,  with  respect  to  their 
connections  with  the  symptoms. 

A.— Constancy  of  the  Lesions  of  the  Digestive  Tube. 

Every  time  an  individual  has  died  of  one  of  the  morbid  groups,  which  charac- 
terise one  of  the  essential  fevers  described  in  the  Nosographie  Philosophique, 
do  we  find  the  digestive  tube  diseased  in  the  dead  body?  Facts  answer  this 
question  in  the  negative.  If  the  cases  given  by  us  in  reference  to  this  point  be 
consulted  again,  there  will  be  found  instances  of  what  are  called  adynamic  or 
ataxic  fevers,  in  which  the  digestive  tube  did  not  present,  after  death,  any  kind  of 
appreciable  lesion.  M.  Bouillaud  has  cited  similar  cases.  The  first  case  in  his 
Traite  des  Fievres  gives  the  history  of  an  individual  who  died  rapidly  with  all 
the  symptoms  of  intense  inflammatory  fever  ( febris  ardens , or  causus  of  the 
ancients),  and  in  whom  no  other  lesion  was  found  in  the  digestive  tube  except 
some  streaks  of  a deep  red  colour  towards  the  splenic  extremity  of  the  stomach  ; 
but  observe,  th e post-mortem  examination  took  place  during  the  heat  of  July, 
more  than  twenty-four  hours  after  death,  and  persons  versed  in  the  study  of 
pathological  anatomy  know  full  well  that,  if  the  body  of  a person  who  has 
died  of  an  acute  disease  under  such  circumstances  be  opened,  nine  times  out  of 
ten  a similar  state  of  the  stomach  will  be  found. 

In  the  twenty-fourth  case  of  the  same  work  there  is  mention  made  of  a person 
who,  five  days  after  having  suffered  comminuted  fracture  of  a limb,  died  with 
all  the  symptoms  of  what  is  called  putrid  or  adynamic  fever.  There  was  no 
morbid  change  discovered  in  the  digestive  tube ; neither  was  there  any  lesion 
in  this  tube  in  the  persons  who  form  the  subject  of  the  twenty-sixth,  twenty- 
seventh,  twenty-eight,  and  twenty-ninth  cases,  and  who,  being  attacked  with 
different  local  affections  (erysipelas,  external  gangrene,  phlebitis,  &c.),  also 
died  with  the  symptoms  called  adynamic,  and  particularly  with  dry  tongue, 
and  teeth  covered  with  black  sordes. 

M.  Louis,  who  considers  lesions  of  the  intestinal  follicles  as  the  anatomical 
character  of  typhoid  fever,  has,  however,  published  some  cases  in  which  neither 
this  lesion,  nor  any  other  worth  remarking,  was  found  in  the  digestive  tube  in 
persons  who,  during  life,  would  certainly  have  been  considered  by  the  Pinel 
school  as  labouring  under  adynamic  fever.  Thus,  in  the  fifty  first  case  of  his 
work,  M.  Louis  thus  describes  the  state  of  the  digestive  tube  of  an  individual 
who  died  on  the  eleventh  day  of  a disease,  during  which  he  presented  the  fol- 
lowing symptoms,  viz.,  delirium,  stupor,  meteorism,  involuntary  stools,  his 
tongue  being  at  first  dry  and  rapeuse,  then  black  and  incrusted. 

“ The  gastric  mucous  membrane  was  of  a greenish  tint,  very  slightly  soft- 


DISEASES  OF  THE  ABDOMEN. 


135 


ened,  its  thickness  being  proportioned  to  its  size.  The  small  intestine  was 
moderately  distended  with  gases,  and  contained  a little  yellow  bile  and  mucus. 
Its  mucous  membrane  presented  the  same  colour  in  some  points,  and  was  in 
general  whitish,  of  a natural  thickness  and  consistence,  except  in  the  four  last 
feet  of  the  ileum,  where  it  was  a little  softened,  all  the  elliptical  patches  were 
healthy.  The  large  intestine  contained  some  faeces  ; its  inner  membrane  was 
greenish  or  yellowish,  and,  except  that,  perfectly  healthy.  The  mesenteric 
glands  were  very  small.” 

The  individual  whose  history  is  detailed  in  the  52d  case  of  M.  Louis’s  work 
presented,  still  more  than  the  preceding,  the  combination  of  all  the  traits  of 
what  is  called  putrid,  ataxo-adynamic,  or  typhoid  fever  ; or,  if  it  be  preferred, 
of  dothinenterite.  At  the  onset  there  was  loss  of  appetite,  vomiting,  diarrhoea ; 
then  intense  pain  of  head,  delirium,  coma,  great  muscular  debility,  eschars  on 
the  sacrum,  spots,  as  it  were  scorbutic,  on  the  skin,  involuntary  stools,  meteo- 
rism,  clammy  dry  tongue,  yet  the  following  is  the  state  in  which  the  digestive 
tube  was  found  : — 

“ The  stomach,  of  moderate  size,  contained  a little  bile  and  some  mucus  ; its 
inner  surface  was  slightly  spotted  with  red  through  its  entire  extent;  the  duo- 
denum was  healthy  ; the  mucous  membrane  of  the  small  intestine  was  pale,  and 
perfectly  healthy  through  its  entire  length  ; the  same  may  be  said  of  the  ellipti- 
cal patches  of  the  ileum,  all  thin,  white,  or  slightly  speckled  with  grey,  as  is 
observed  in  the  natural  state  ; the  mucous  membrane  of  the  large  intestine  was 
white,  softened  in  the  right  colon  ; then  it  increased  all  at  once  in  consistence  ; 
the  mesenteric  glands  were  pale,  small,  and  healthy.” 

At  the  commencement  of  the  year  1829,  M.  Dalmas  examined  in  the  Charite 
the  body  of  a person,  fifteen  years  of  age,  who  had  been  considered  as  labouring 
under  typhoid  fever,  and  whose  digestive  tube  was  found  perfectly  healthy. 

Dr.  Martinet  met  a very  remarkable  case  in  the  Hotel  Dieu,  in  which,  to 
explain  the  symptoms  of  the  ataxo-adynamic  fever  of  Pinel, "nothing  was  found 
but  softening  of  the  liver,  and  nothing  in  the  digestive  tube. 

Dr.  Neumann,  physician  of  the  Charite  at  Berlin,  did  not  appear  to  be  ac- 
quainted with  the  works  of  M.  Bretonneau  on  Dothinenterite,  when,  in  1816, 
he  published  a paper  on  a species  of  fever  which  he  considered  as  prevailing 
every  year  epidemically  in  Berlin,  and  which  he  compared  to  typhus.  The 
general  description  which  he  gives  of  it  is  what  might  be  drawn  up  by  com- 
bining what  our  own  cases  present  in  common  with  those  of  MM.  Petit,  Bouil- 
laud,  Louis,  etc.  In  those  who  died,  M.  Neumann  says  he  found,  towards  the 
termination  of  the  small  intestine,  patches  and  ulcerations;  in  a word,  that 
group  of  lesions  which  constitute  our  intestinal  exantheme,  or  the  dothinenterite 
of  M.  Bretonneau.  Still,  though  these  lesions  may  have  been  met  with  by  M. 
Neumann  in  the  majority  of  the  cases,  there  are  some  in  which  he  did  not  find 
them  ; there  was,  on  the  inner  surface  of  the  intestine,  merely  a slight  injection 
of  the  capillaries;  sometimes  even  this  injection  was  absent,  and  in  the  post- 
mortem examination  presented  no  trace  of  disease  in  the  digestive  passages. 

In  the  febrile  disease,  which  is  endemic  in  several  parts  of  Great  Britain,  and 
which,  in  its  symptoms,  bears  the  greatest  resemblance  to  our  continued  fevers, 
there  have  been  frequently  found,  within  the  digestive  tube,  alterations  similar 
to  those  presented  to  us  in  the  greater  number  of  our  cases.  However,  in  some 
cases,  Dr.  Alison,  of  Edinburgh,  to  whom  we  are  indebted  for  an  excellent 
description  of  this  disease,  states,  that  he  had  not  met  with  either  exanthematous 
patches,  ulcerations,  or  any  other  lesion  in  the  digestive  passages.  We  are 
bound  to  place  so  much  the  more  confidence  in  the  researches  of  this  physician, 
as,  at  the  time  he  was  engaged  in  them,  it  was  after  leaving  Paris,,  where  he  had 
been  present  at  several  post-mortem  examinations  of  persons  who  died  of  typhus 
fever,  and  because,  at  Edinburgh,  he  examined  several  bodies,  expecting  to  find 


136 


ANDRAL’S  MEDICAL  CLINIC. 


these  same  patches,  these  same  exanthemes,  and  this  same  redness,  which  be 
had  seen  at  Paris,  and  of  which  he  had  read  the  description  in  French  works. 

On  comparing  with  these  facts,  seen  by  different  persons  and  in  different  places, 
the  facts  which  we  have  ourselves  collected  and  cited  in  all  their  details  in  our 
cases,  we  think  ourselves  warranted  in  laying  down  the  following  proposition  : — 

In  the  pyrexise  which  constitute  the  different  morbid  groups  designated  in 
PineVs  Nosographie  by  the  name  of  essential  fevers , we  do  not  always  find , 
after  death , lesions  in  the  digestive  tube. 

Whence  it  follows  that  several  of  these  morbid  groups  may  have  an  existence 
independent  of  that  of  a gastro-intestinal  affection. 

B. — Frequency  of  the  lesions  of  the  digestive  tube. 

If  these  lesions  are  not  constant,  are  they  at  least  so  frequent,  that,  in  conse- 
quence of  this  frequency,  they  acquire  nearly  as  much  importance  as  if  they  were 
never  absent  ? 

Since  M.  Broussais  has  ealled  the  attention  of  medical  men  to  the  state  of  the 
digestive  tube  in  fever,  innumerable  facts  have  shown  that,  in  almost  all  the  cases 
where  the  body  of  a person  who  died  during  the  course  of  what  is  called  an  es- 
sential fever  was  examined,  the  digestive  tube  was  found  to  be  diseased.  Our 
own  observation  fully  confirms  these  results,  which  may  be  expressed  in  the 
following  terms  : 

In  the  pyrexise  which  constitute  the  different  morbid  groups  designated  by 
the  name  of  essential  fever,  lesions  of  the  digestive  tube  are  found  very  fre- 
quently after  death,  ninety-eight  times  out  of  one  hundred. 

Whence  it  follows  that  lesions  of  the  digestive  tube  perform  a very  important 
part  in  those  diseases,  and  that  they  should  be  taken  into  consideration,  whether 
the  question  be  to  ascend  to  the  nature  of  these  fevers,  or  to  determine  the  treat- 
ment to  be  employed.  The  frequency  of  intestinal  lesions  in  fever  has  so  con- 
vinced us  of  their  importance,  that,  though  we  know  them  to  be  sometimes  want- 
ing, and  also  that,  when  they  do  exist,  they  cannot  explain  everything,  still  we 
thought  it  right  to  speak  of  fevers  in  the  portion  of  our  Clinique  especially  dedi- 
cated to  diseases  of  the  abdominal  organs. 

C. — Seat  and  nature  of  the  lesions  of  the  digestive  tube. 

The  digestive  tube,  examined  from  the  cardiac  orifice  of  the  stomach  to  the 
termination  of  the  rectum,  is  not  found  altered  with  equal  frequency  in  its  differ- 
ent parts  in  persons  who  die  during  the  course  of  continued  fevers. 

a. — Stomach. 

In  several  subjects  we  have  found  this  organ  exempt  from  all  appreciable  lesion. 
It  was  very  white  through  its  entire  extent ; some  few  veins  merely  were  marked 
beneath  its  mucous  membrane.  This  membrane,  as  well  as  the  other  tunics, 
were  everywhere  of  the  natural  consistence  ; neither  were  they  thinner  nor 
thicker  than  in  their  normal  state. 

In  other  subjects,  and  these  were  more  numerous  than  the  preceding,  the  in- 
ner surface  of  the  stomach  presented  in  some  points  red  spots,  resulting  from  the 
aggregation  of  a number  of  small  vessels  minutely  injected.  Sometimes  the 
spots,  when  combined,  occupied  a space  scarcely  large  enough  to  hold  from  a 
five  to  a forty  sous  piece;  sometimes,  and  this  latter  case  was  more  uncommon 
than  the  preceding,  one-third,  or  even  one-half,  of  the  stomach  presented  this  kind 
of  injection. 

At  other  times  the  inner  surface  of  the  stomach  was  found  generally  injected, 
this  injection,  however,  being  but  slight. 


DISEASES  OF  THE  ABDOMEN. 


137 


This  injection  wa3  observed  more  frequently  towards  the  great  cul-de-sac  than 
in  the  other  parts  of  the  stomach. 

In  some  cases  we  found  the  red  tint  replaced  by  a brown  slate-colour  or  yel- 
low tint.  In  a very  inconsiderable  number  of  cases  we  have  detected  the  exist- 
ence of  ecchymoses  of  small  extent  in  the  submucous  cellular  tissue  ; these  ecehy- 
moses  were  found  more  particularly  to  occupy  the  splenic  portion  of  the  stomach. 

Two  or  three  times  we  found  considerable  increase  in  the  consistence  of  the 
gastric  mucous  membrane ; but  we  very  frequently  observed  considerable  soft- 
ening of  this  membrane.  This  softening  was  not  equally  frequent  over  all  parts 
of  the  stomach  ; whilst  it  was  very  rarely  met  in  the  pyloric  portion,  or  on  the 
anterior  or  posterior  surfaces  of  the  stomach,  it  was  found  to  be  a very  common 
lesion  in  the  great  cul-de-sac.  With  respect  to  its  colour,  it  presented  three 
varieties,  a white,  a grey  or  brown,  and  a red. 

In  one  case  only  this  softening  was  not  confined  to  the  mucous  membrane  ; all 
the  coats  had  been  affected  with  it ; the  slightest  force  was  sufficient  to  tear 
them  ; in  several  points  also  the  mucous,  cellular,  and  muscular  coat,  had  dis- 
appeared altogether ; and  the  parietes  of  the  stomach  consisted  on  these  points 
merely  of  the  serous  membrane,  which  was  itself  become  very  friable.  This 
remarkable  softening  existed  also  without  redness,  or  any  other  unusual  colour. 

On  one  occasion  the  mucous  membrane  of  the  stomach  presented  a great  num- 
ber of  ulcerations,  all  similar  in  form  and  size  ; and  another  time  we  found  the 
stomach  completely  perforated  in  its  splenic  portion. 

The  substances  contained  in  the  stomach  rarely  presented  to  us  any  peculiari- 
ties worth  remarking.  In  general  it  contained  nothing  bdt  the  drinks  swallowed 
by  the  patients,  and  some  gases.  We  have  never  found  any  very  great  quantity  of 
mucus  in  the  stomach,  and  it  was  but  in  very  few  instances  it  contained  any 
bile.  In  an  individual  who  a few  hours  before  death  was  seized  with  profuse 
black  vomiting,  the  inner  surface  of  the  stomach  was  covered  with  a substance 
similar  to  that  of  the  vomit ; this  appeared  to  be  nothing  but  blood  changed  in 
its  colour  and  in  some  of  its  properties  by  its  stay  in  the  stomach. 

The  natural  size  of  the  stomach  we  very  rarely  found  changed.  Two  or  three 
times  only  we  found  it  so  contracted  towards  the  pyloric  portion,  that  in  this  part 
it  scarcely  equalled  the  small  intestine  in  size  : in  this  case  the  mucous  mem- 
brane was  not  more  diseased  than  in  other  cases  where  no  such  contraction 
existed. 

Such  are  the  different  states  in  which  we  found  the  stomach  of  persons  who 
died  during  the  progress  of  continued  fevers.  In  all  this  there  is  nothing  pecu- 
liar, nothing  which  is  not  found  in  the  stomachs  of  persons  who  may  have  died 
of  any  other  disease.  In  a great  number  of  bodies  we  find  these  injections,  these 
red  and  coloured  appearances,  these  ecchymoses,  and  softenings,  without  there 
having  been  during  life  any  symptoms  resembling  the  symptoms  of  what  are 
called  essential  fevers ; these  morbid  changes  do  not  belong  more  to  acute  than 
to  chronic  diseases  ; several  too  may  be  justly  considered  as  a purely  cadaveric 
result.  With  respect  to  the  ulcerations  which  we  once  found  in  the  stomach, 
and  the  perforation  once  observed  by  us  in  this  organ,  such  morbid  changes  are 
also  met  in  other  diseases,  nor  can  they  explain  the  symptoms,  except  for  the 
very  cases  in  which  they  have  been  observed. 

What  we  have  just  now  said  is  confirmed  by  the  result  of  M.  Bouillaud’s  cases, 
as  also  those  of  M.  Louis,  who  have  found  in  the  stomach  alterations  in  no  way 
differing  from  those  which  we  have  just  described. 

From  these  facts  we  feel  warranted  in  laying  down  the  following  proposi- 
tions : — 1.  The  stomach  is  found  healthy  in  a considerable  number  of  persons 
who  die  during  the  progress  of  what  is  called  essential  fever,  whatever  may  have 
been  the  symptomatic  form  of  this  fever. 

2.  The  changes  found  in  the  stomach  of  persons  who  die  during  the  progress 


138 


AN  DUAL’S  MEDICAL  CLINIC. 


of  this  fever  have  nothing  peculiar,  nothing  which  can  constitute  their  anatomical 
character. 

3.  These  changes  differ  not  from  those  discovered  in  the  bodies  of  persons  who 
have  died  of  any  other  disease,  whether  acute  or  chronic. 

4.  They  are  met  with  nearly  equal  frequency,  both  in  those  who  have  died 
during  continued  fever,  and  in  those  who  have  died  of  a different  disease.* 

5.  Every  fever  called  essential  is  not  necessarily  the  product  of  gastritis. 

6.  The  traces  of  gastritis  found  on  opening  bodies  cannot  always  suffice  to 
explain  the  different  morbid  groups  called  essential  fevers. 

7.  Before  placing  the  cause  of  these  diseases  in  an  inflammatory  state  of  the 
stomach,  it  would  be  necessary  to  commence  by  deducting  from  that  which  may 
characterise  this  inflammatory  state  the  different  changes  which  may  be  owing  to 
any  other  cause  than  a process  of  irritation,  and  several  of  which  are  not  formed 
till  after  death. f It  would  be  then  found  that  the  number  of  the  cases  wherein 
one  may  refer  the  fever  to  a gastric  inflammation  becomesless  considerable  than 
one  would  at  first  be  inclined  to  think. 

8.  There  are,  however,  cases  where  acute  gastritis  should  be  considered  as  the 
onset  of  typhoid  fever, 


b. — Small  intestine* 

The  morbid  changes  of  the  small  intestine,  considered  with  respect  to  their  seat, 
are  found  so  much  the  more  numerous  according  as  this  part  of  the  digestive  tube 
is  closer  to  its  union  with  the  large  intestine. 

Thus  we  have  very  seldom  found  the  duodenum  affected.  It  was  but  in  very 
rare  cases  also,  that  the  rest  of  the  large  intestine  in  its  upper  four-fifths  presented 
any  lesion  ; on  the  contrary,  it  is  in  the  lower  fifth  of  this  same  intestine  that  we 
have  found  the  most  constant  and  marked  lesions  in  persons  who  die  during  the 
course  of  a continued  fever. 

Let  us  now  pass  in  review  the  different  states  in  which  this  intestine  is  found. 

1.  The  healthy  state.  This  is  the  most  uncommon  occurrence  ; some  ofour 
cases  show,  however,  that  the  small  intestine  may  present  no  sort  of  morbid 
change  after  different  kinds  of  fever. 

2.  A state  healthy  at  the  time  of  the  post-mortem  examination,  with  traces  of 
a disease  which  terminated  recently. 

In  some  of  our  patients  who  died  of  any  affection  during  convalescence  from 
a bad  fever,  we  have  found  on  the  inner  surface  of  the  termination  of  the  small 
intestine  either  the  aggregated  crypts,  or  Brunner’s  follicles,  much  more  apparent 
than  usual ; each  of  their  orifices  was  marked  by  a greyish  point ; in  other  re- 
spects they  presented  no  morbid  appearance.  We  thought  it  possible  that  this 
unusual  development  of  the  follicles  depended  on  their  having  been  affected  some 
time  before  death,  during  the  very  course  of  the  fever;  we  examined  them  at  a 
time  when  they  were  returned  to  their  normal  state. 

In  other  patients,  who  also  died  during  convalescence,  it  was  no  longer  these 
follicular  patches  that  we  observed  ; but,  in  the  place  where  they  usually  exist, 
a close  examination  showed  us  that  the  mucous  membrane,  far  from  being  thick- 
ened, was,  on  the  contrary,  thinner  than  in  the  intermediate  points;  there  were 
no  longer  villi  to  be  observed  there ; there  was  only  found  there  a thin,  and,  as 
it  were,  cellulo-vascular  layer,  which  seemed  to  be  mucous  membrane  reduced 
to  its  most  simple  state.  It  appeared  to  us  that  there  was  a newly-formed  mem- 
brane there,  which  had  just  taken  the  place  of  cicatrised  ulcers. 

3.  The  erythematous  state. 

* The  researches  which  have  led  us  to  establish  this  fourth  proposition  are  entirely  confirm- 
atory of  those  of  M.  Louis. 

-f-  See,  on  this  point  of  doctrine,  our  work  on  Pathological  Anatomy. 


DISEASES  OF  THE  ABDOMEN. 


139 


All  the  shades  of  vascular  injection  which  have  been  found  in  the  intestinal 
mucous  membrane*  were  presented  to  us  in  the  diseases  now  under  considera- 
tion. It  is  principally  towards  the  lower  part  of  the  small  intestine  that  this  in- 
jection is  commonly  observed.  It  sometimes  exists  as  the  sole  lesion  — a rather 
rare  occurrence,  but  yet  one  of  which  we  have  met  instances;  sometimes  it 
exists  as  a secondary  lesion,  around  other  morbid  changes,  of  which  we  shall 
speak  at  another  time. 

There  are  cases  where  the  surface  itself  of  the  mucous  membrane  is  scarcely 
coloured,  whilst  the  villi  alone  are  very  much  injected.  Dr.  Scoutetten  has  lately 
directed  our  attention  to  this  peculiar  sort  of  injection,  which  we  have  seen 
more  than  once,  and  which  he  considers  as  much  calculated  to  produce  continued 
fevers,  as  lesion  of  the  follicles. 

4.  The  exanthematous  state. 

By  this  term  we  mean  to  designate  that  species  of  eruption  which  is  found  as 
a peculiar  lesion  on  the  inner  surface  of  the  termination  of  the  small  intestine,  in 
persons  who  have  died  during  the  course  of  continued  fevers,  whether  of  a mild 
or  severe  form.  Intestinal  exantheme,  very  clearly  pointed  out  by  MM.  Petit 
and  Serres,  described  by  us  in  the  first  edition  of  our  Clinique,  still  better  appre- 
ciated as  to  its  nature  by  M.  Bretonneau,  traced  out  through  all  its  varieties  by  M. 
Louis,  constituted  the  first  stage  of  the  disease  called  dotbinenterite  by  M.  Bre- 
tonneau. It  is  unnecessary,  at  the  present  day,  to  attempt  to  prove  that  this  ex- 
antheme is  seated  in  the  intestinal  follicles.  Should  it  attack  those  aggregations 
of  cryptae,  known  by  the  name  of  Peyer’s  patches,  we  find,  in  the  lower  fifth  of 
the  intestine,  patches  usually  of  an  oval  form,  of  variable  size,  and  which  form 
above  the  level  of  the  mucous  membrane  a prominence  of  some  lines  ; some  are 
of  a more  or  less  bright  red  ; others  are  grey,  yellow  or  blackish,  and  then  resem- 
ble eschars  ; others  are  of  a dull  white.  They  are  sometimes  harder  than  the  mu- 
cous membrane  surrounding  them  ; sometimes,  on  the  contrary,  they  are  very 
friable,  and  readily  reduced  to  a pulp.  There  are  cases  where  the  form,  &c., 
of  the  follicles  may  be  readily  recognised  on  their  free  surface ; their  orifices 
are  found,  and  these  small  bodies,  whose  form  has  only  become  more  distinct 
by  their  increase  in  size,  are  separated  by  perceptible  intervals,  which  are  more 
easily  penetrated  by  the  rays  of  light.  There  are  other  cases  where  these  folli- 
cles are  no  longer  distinct,  and  where  the  entire  patch  merely  resembles  a ho- 
mogeneous mass,  whose  elementary  structure  has  ceased  to  be  appreciable  ; 
then  these  patches  can  no  longer  be  regarded  as  belonging  to  enlarged  follicles, 
except  in  consequence  of  their  form  and  seat. 

It  must  not  be  supposed  that  these  patches  are  formed  solely  by  the  enlarge- 
ment of  the  follicles ; very  often  beneath  the  latter  we  find  the  cellular  layer 
itself  very  much  thickened,  and  it  then  participates  as  much  as  the  follicles  in 
the  production  of  the  exantheme. 

This  exantheme  may  terminate  in  several  ways.  N There  are  cases  less 
numerous,  however,  than  has  been  stated,  where  real  gangrene  seems  to  attack 
it ; one  or  more  patches  then  become  detached  like  eschars,  leaving  an  ulcer 
in  their  place.  At  other  times,  without  there  being  any  proof  of  the  existence 
of  previous  gangrene,  the  exanthematous  patch  is  destroyed  in  several  points. 
Hence  there  are  formed  on  its  free  surface  several  small  ulcers,  which  enlarge 
and  ultimately  unite ; and  thus  the  complete  disappearance  of  the  exantheme 
is  at  length  brought  about.  In  other  cases  this  exantheme  has  a different  ter- 
mination ; it  loses  its  redness,  seems  to  become  indurated,  and  now  presents, 
on  the  internal  surface  of  the  intestine,  merely  patches  of  a duller  white  than 
the  rest  of  the  mucous  membrane.  These  patches  may  continue  for  a longer 
or  shorter  time  without  producing  any  symptoms,  or,  at  least,  without  being 


* See  Pathological  Anatomy. 


140 


ANDRAL’S  MEDICAL  CLINIC. 


accompanied  by  those  general  phenomena  which  had  at  first  coincided  with 
their  enlargement.  This  is  the  transition  of  the  lesion  from  the  acute  to  the 
chronic  state.  This  exantheme  may  even  terminate  in  simple  resolution;  then 
the  patches  forming  it  become  gradually  effaced,  and  in  their  stead  we  find 
only  those  oblong  bands,  with  grey  or  black  points,  which  we  have  already 
described  in  some  of  our  particular  cases. 

There  is  another  exantheme  which  is  also  observed  on  the  inner  surface  of 
the  small  intestine,  in  the’ same  cases  as  the  preceding.  Like  this,  it  princi- 
pally occupies  the  part  of  the  intestine  nearest  to  the  caecum  ; but,  instead  of 
appearing  in  the  form  of  broad  oval  or  oblong  patches,  it  appears  under  that  of 
papulae  separated  from  each  other,  red,  grey,  or  whitish,  of  a conical  form,  most 
frequently  presenting,  on  their  summit,  an  orifice  from  which  a mucous  or 
purulent  fluid  is  forced  out  by  pressure.  On  examining  a certain  number  of 
these  papulae,  there  are  some  found  without  any  trace  of  orifice,  whilst  others, 
on  the  contrary,  are  found  whose  orifice,  constantly  enlarging,  is  changed  into 
an  ulcer,  which,  commencing  at  the  summit  of  the  papulae,  extends  gradually 
to  its  base.  Sometimes  we  find  only  some  of  these  papulae  scattered  in  small 
numbers  on  the  inner  surface  of  the  intestine  ; sometimes  they  are  in  immense 
quantities ; and  if  they  are  at  the  same  time  depressed  on  their  summit,  as 
happens  when  they  commence  to  ulcerate,  there  appears,  on  the  inner  surface 
of  the  intestine,  an  eruption  which  bears  a very  striking  resemblance  to 
small-pox. 

Like  the  exantheme  in  patches,  the  pustular  exantheme,  which  has  been  just 
described,  has  its  seat  evidently  in  the  intestinal  follicles.  The  difference  in 
form  between  these  two  exanthemes  depends  solely  on  this  circumstance,  that 
the  former  consists  of  aggregated  follicles,  and  the  latter  of  separate  follicles. 

When  we  examine  the  small  intestine  of  persons  who  have  died  a little  time 
after  having  had  a bad  fever,  it  sometimes  happens  that,  with  or  without  the  grey 
or  black-pointed  patches  of  which  we  have  spoken,  we  also  find  traces  of  in- 
flammation of  the  separate  follicles  (called  Brunner's  Follicles ).  There  is 
then  perceived,  on  the  inner  surface  of  the  intestine,  a greater  or  less  number 
of  small  white  or  grey  bodies,  of  considerable  consistence,  in  the  centre  of 
which  there  is  found  a blackish  blue  point.  Who  could  avoid  recognising  in 
these  bodies  follicles  a little  more  developed  than  usual? 

It  has  been  stated  that  both  varieties  of  the  intestinal  exantheme  which  have 
been  just  described  observed  fixed  periods  in  their  development,  similar  to  those 
observed  by  the  eruption  of  small-pox;  so  that,  knowing  the  stage  of  the  dis- 
ease at  which  death  supervened,  one  might  tell,  before  opening  the  body,  in 
what  stage  the  exantheme  might  be  found ; whether,  for  instance,  it  was  still 
intact,  or  already  ulcerated,  &c.  Our  observation  has  not  led  us  to  the  same 
result.  We  have  found  the  follicles  ulcerated  in  persons  who  died  a few  days 
after  the  commencement  of  the  disease;  and,  on  the  contrary,  it  has  happened 
us  more  than  once  to  meet  only  simple  exantheme,  without  any  appearance  of 
ulceration,  in  persons  who  had  not  died  till  the  disease  had  existed  for  a very 
long  time. 

Neither  do  we  consider  it  correct  to  say  that  the  exantheme  in  patches  or  in 
pustules  has  a necessary  tendency  to  ulceration,  and  consequently  that  a person 
cannot  recover  till  after  the  patches  or  papulae  have  been  changed  into  ulcera- 
tions, and  the  latter  then  cicatrised.  The  eschar,  whose  fall,  it  has  been  said, 
occasions  the  ulceration,  is  but  one  of  the  possible,  and  by  no  means  a neces- 
sary, termination  of  the  exantheme;  and  a person  may  very  well  recover  from 
a continued  fever  after  having  had  only  an  exanthematous  inflammation  of  the 
follicles,  without  eschar,  suppuration,  or  previous  ulceration.  This  has  been 
confirmed  by  M..  Bretonneau. 

The  state  of  the  mucous  membrane  between  the  patches  and  the  papula)  should 


DISEASES  OF  THE  ABDOMEN. 


141 


also  engage  our  attention.  It  presents  itself  under  two  different  aspects  ; some- 
times it  is  white  in  every  point,  and  presents  no  trace  of  disease  whatever  ; the 
disease  is  then  confined  solely  to  the  follicles  ; sometimes,  on  the  contrary,  this 
membrane  is  also  diseased  in  the  intervals  between  the  follicles  ; it  is  either 
simply  injected  in  different  degrees,  or  changed  in  different  degrees  with  respect 
to  its  consistence. 

Once  it  was  ascertained  that  no  lesion  is  more  frequent  in  continued  fevers 
than  intestinal  exantheme  or  dothinenterite,  as  it  is  called  by  M.  Bretonneau  : a 
very  important  point  remained  to  be  established.  It  then  became  necessary  to 
determine  whether,  in  the  individuals  who  died  during  the  progress  of  other 
diseases  than  fevers,  this  exantheme  were  also  found  ; for,  if  it  so  happened 
that  it  had  been  met  in  every  affection  as  frequently  as  a hyperemia  or  a soften- 
ing of  the  stomach,  it  is  evident  that  this  exantheme  would  have  lost  its  value 
as  an  anatomical  character  of  what  are  called  essential  fevers. 

But  such  is  not  the  case.  In  vain  have  we  very  frequently  sought  for  this 
exantheme  in  the  intestine  of  individuals  who  died  of  other  acute  diseases  than 
fevers.  We  did  not  meet  it;  we  merely  found  in  different  subjects  a very  un- 
equal development  of  the  follicles,  but  nothing  which  resembled  the  exantheme 
of  fever. 

If  we  examine  the  intestine  in  cases  of  chronic  disease,  we  shall  find  one, 
namely,  pulmonary  phthisis,  where  the  ileum  presents  a morbid  change,  which 
approximates,  more  than  any  other,  to  the  exantheme  of  fevers.  This  change 
is  also  seated  in  the  aggregated  follicles,  which  become  very  prominent,  are  of 
an  oval  form,  and  on  the  surface  of  the  intestine.  On  making  an  incision  over 
these  follicles,  a tuberculous  matter  is  expressed  from  them  which  fills  the  fol- 
licles, and  to  which  their  tumefaction  is  principally  owing.  In  this  case  the 
chronic  progress  of  the  affection  is  sufficient  to  occasion  a prodigious  difference 
in  the  symptoms  ; but  still  this  case  proves  that  the  aggregated  follicles  of 
Peyer  may  be  affected  and  changed  into  exanthematous  patches  in  other  dis- 
eases as  well  as  in  continued  fevers. 

M.  Louis,  to  whose  testimony  we  frequently  appeal,  has  also  sought  for  the 
intestinal  exantheme  in  many  other  acute  diseases  besides  fever,  and  has  never 
met  it,  more  than  ourselves,  except  in  one  case  of  scarlatina,  in  which  he  found 
those  of  the  elliptical  patches  very  red  and  a little  thickened.  In  this  case  the 
existence  of  scarlatina  was  not  well  ascertained,  and  the  person  died  on  the  se- 
cond day  of  his  admission  into  the  hospital,  before  the  particulars  of  the  disease 
could  be  well  collected.  In  three  other  cases  of  scarlatina,  and  in  two  other 
cases  which  he  does  not  specify,  M.  Louis  found  a very  considerable  develop- 
ment of  Brunner’s  follicles.  We  have  discovered  the  development  of  these 
separate  follicles  more  frequently  than  M.  Louis  in  persons  who  died  of  other 
acute  diseases  besides  fever  ; so  that  we  are  inclined  to  think  that  their  de- 
velopment belongs  less  exclusively  to  these  affections  than  that  of  the  aggre- 
gated follicles.* 

.5.  Ulcerations. 

It  is  in  the  part  of  the  small  intestine,  where  the  exantheme  is  developed,  that 
the  ulcerations  are  almost  exclusively  detected.  In  many  cases  it  is  easy  to  see 
that  they  arise  from  the  destruction  either  of  the  elliptical  patches  or  of  Brunner’s 
follicles.  They  are  seen  to  commence  on  the  very  surface  of  these  patches,  or 
at  the  summit  of  these  follicles  ; and,  even  in  one  and  the  same  intestine,  one 
may  trace  all  their  progress,  even  to  the  complete  disappearance  of  the  follicles. 
There  are  some  subjects  in  whom  we  find,  in  a small  portion  of  the  intestine, 

* One  of  the  most  constant  lesions  which  we  met  in  the  epidemic  cholera  was  tumefaction 
of  the  intestinal  follicles,  both  the  separated  and  the  aggregated.  But  the  patches  and  papulae 
in  this  case  project  but  slightly  above  the  level  of  the  mucous  membrane,  and  their  colour  is 
generally  white. 


142 


ANDRAL’S  MEDICAL  CLINIC. 


beside  each  other,  first,  some  patches  intact secondly,  isolated  follicles,  also 
intact;  thirdly,  patches  and  follicles  beginning  to  become  ulcerated;  fourthly, 
simple  ulcerations.  At  other  times  it  is  only  by  analogy  it  can  be  admitted  that 
these  ulcerations  succeeded  a destruction  of  the  follicles.  Nothing  proves  that 
there  was  previous  engorgement  of  these  bodies.  In  this  case,  however,  the 
ulcerations  occupy  the  same  part  of  the  intestine  as  in  the  preceding  case  ; they 
are  of  the  same  form,  and  have  the  same  aspect.  They  are  almost  always  found 
like  the  elliptical  patches,  towards  the  part  of  the  intestine  opposite  to  that  which 
gives  attachment  to  the  mesentery.  Some  of  them  are  regularly  rounded,  others 
are  altogether  like  Peyer’s  patches;  several  of  them,  when  enlarging,  frequently 
unite  into  a single  one,  which  then  occupies  a considerable  extent.  It  is  not 
uncommon  to  see  the  upper  surface  of  the  ileo-caecal  valve  changed  into  one 
large  ulceration ; neither  is  it  uncommon  to  find  the  mucous  membrane 
of  the  small  intestine  completely  destroyed  to  the  extent  of  six  or  eight  inches 
above  the  valve.  At  other  times,  on  the  contrary,  nothing  is  found  but  very  small 
ulcerations,  scarcely  as  large  as  a five-sous  piece,  or  even  much  smaller. 

The  bottom  and  edges  of  these  ulcerations,  and  the  portions  of  mucous  mem- 
brane situate  between  them,  present  several  aspects,  which  it  is  important  to 
distinguish. 

Their  bottom  may  be  formed  either  by  the  sub-mucous  cellular  tissue,  or  by  the 
muscular  tunic,  or  merely  by  the  peritoneum.  When  it  is  the  cellular  tissue,, 
sometimes  it  is  thin  and  pale,  and  differs  in  no  respect  from  what  it  is  in  its. 
normal  state.  Sometimes  it  is  very  perceptibly  thickened,  as  it  were  wrinkled, 
and  usually  coloured  either  red,  greyish,  yellow,  or  black.  To  some  points  of 
its  free  surface  there  are  still  attached  some  debris  of  the  mucous  membrane, 
ready  to  separate  like  eschars. 

When  it  is  the  muscular  layer  that  forms  the  bottom  of  these  ulcerations,  it 
is  occasionally  found,  like  the  cellular  layer,  either  in  its  natural  state,  or 
changed  in  its  consistence  and  colour. 

When  there  is  nothing  at  the  bottom  of  these  ulcerations  but  the  peritoneal 
tunic,  this  membrane  may  be  so  fragile  that  the  slightest  force  is  sufficient  to 
tear  it ; so  that,  if  the  individual  had  lived  for  some  time  longer,  a cause  entirely 
mechanical — as,  for  instance,  the  distension  of  a part  of  the  intestine  by  gases 
— would  have  been  sufficient  to  produce  intestinal  perforation. 

The  edges  of  the  ulcerations  are  formed  by  the  mucous  membrane,  which  is 
sometimes  red  and  thickened,  and  sometimes  white  and  thin. 

With  respect  to  the  portions  of  mucous  membrane  situate  between  the  ulcera- 
tions, they  are  often  injected,  softened,  or  exanthematous  ; but  frequently  they 
present  no  kind  of  appreciable  alteration  ; they  may  even  be  perfectly  white. 

We  have  more  particularly  met  these  ulcerations  with  whiteness,  and  other 
normal  qualities  of  the  tissues,  which.form  their  bottom  and  edges,  in  cases  where, 
at  the  time  of  death,  the  individuals  were  bordering  on  convalesence,  or  might 
even  be  already  considered  as  convalesent.  We  are  inclined  to  think  that  the 
ulcerations  found  in  this  state  are  in  progress  of  cure. 

But  there  are  other  cases  where  this  cure  is  still  more  advanced,  and  where  the 
particular  state  in  which  some  points  of  the  intestine  are  found,  can  be  considered 
as  nothing  else  than  a real  process  of  cicatrisation  more  or  less  advanced.  Case 
27th  presented  us  with  an  instance  of  this  cicatrisation.  It  might  be  so  much  the 
more  readily  admitted  in  this  case,  as  the  individual  whose  intestine  we  found  in 
this  particular  state,  which  we  considered  as  the  sign  of  a cicatrised  ulceration, 
had  died  during  convalescence  from  a typhus  fever.. 

The  cicatrisation  of  ulcerations,  supervening  under  the  same  circumstances, 
have  been  also  noticed  by  MM.  Bouillaud  and  Louis.  In  a patient  who  died  of 
gangrenous  erysipelas  of  a limb,  forty-three  days  after  the  invasion  of  the  fever, 
the  symptoms  of  which  were  amended  at  the  time  of  death,  M.  Louis  found  near. 


DISEASES  OF  THE  ABDOMEN. 


143 


the  caecum  several  ulcerations , the  circumference  of  which  was  depressed , and 
whose  centre  was  lined  by  an  extremely  thin  pellicle , as  it  were  a serous  mem- 
brane, continuous  with  the  sub-mucous  tissue  of  the  circumference.  In  another 
individual,  who  also  died  when  all  the  signs  of  convalescence  had  made  their  ap- 
pearance, the  same  observer  detected  one  of  Peyer’s  patches,  which,  in  a part 
of  its  extent,  was  smooth,  polished,  depressed,  and  divested  of  mucous  mem- 
brane. “ The  latter,”  says  M.  Louis,  whose  own  very  words  we  cite,  “ termi- 
nated near  the  circumference  of  the  patch,  and  adhered  at  this  point  to  an  ex- 
tremely thin  pellicle,  resembling  a serous  membrane  in  appearance,  which 
covered  the  muscular  tunic,  and  was  continuous  with  the  sub-mucous  tissue.” 

In  the  two  cases  cited  by  M.  Louis  a new  mucous  membrane  was  not 
formed  ; on  the  contrary,  in  the  cases  given  by  us,  there  appeared  to  have  been 
a reproduction  of  the  mucous  membrane  itself,  but  a mucous  membrane  possess- 
ing neither  villi  nor  follicles. 

In  our  cases  there  will  be  found  some  instances  where,  though  the  individuals 
died,  as  the  preceding  did,  during  their  convalescence,  the  ulcerations,  still  very 
well  marked,  presented  no  tendency  to  cicatrisation.  Similar  facts  have  been 
noticed  by  M.  Louis  ; they  lead  us  to  this  conclusion,  that  the  general  symp- 
toms which  constitute  fever  are  not  so  connected  with  the  intestinal  lesion,  that 
they  may  disappear,  though  the  latter  still  exists  ; but,  from  these  facts,  we 
should  not  draw  the  inference  that  the  intestinal  lesion  did  not  produce  the 
fever ; for  the  mere  transition  of  this  lesion  to  a less  acute  state  might  suffice  to 
explain  the  cessation  of  the  sympathies,  and  consequently  of  the  fever.  Besides, 
is  not  this  the  case  with  all  the  lesions  of  our  different  organs?  May  they  not 
all  exist  in  a completely  latent  state,  either  in  a continued  form,  or  only  at  in- 
tervals ? And  observe  well,  that  in  all  it  is  not  only  the  general  symptoms 
which  may  be  wanting  ; there  may  also  be  a complete  absence  of  the  local 
symptoms.  Recollect  those  numerous  cases  of  latent  pneumonia  which  we 
have  so  frequently  met,  and  which  were  not  announced  either  by  cough,  dys- 
pncea,  or  the  expectoration. 

6.  Perforations.* 

These  must  be  considered  as  one  of  the  terminations  of  those  different  lesions 
now  passed  in  review.  They  are  the  immediate  cause  of  death  in  a certain 
number  of  persons  labouring  under  continued  fever.  Their  most  frequent  seat 
is  either  the  exanthematous  patches  above  described,  or  the  ulcerations  which 
have,  or  have  not,  succeeded  to  these  patches. 

The  probability  of  perforations  is  not  always  in  a direct  ratio  of  the  number, 
extent,  or  severity  of  the  ulcerations,  or  other  intestinal  lesions.  Our  tenth  case 
presented  us  with  an  instance  of  intestinal  perforation  coming  on  in  an  individual 
in  whose  intestine  we  only  found  an  ulceration  of  a very  small  diameter,  with 
some  very  small  patches  around  it. 

Intestinal  perforations  come  on  only  at  an  advanced  period  of  the  disease, 
when  the  symptoms  of  what  is-  called  adynamic  fever  are  already  present.  The 
result  is  peritonitis,  which,  in  many  cases,  developes  itself  by  its  usual  signs, 
but  which,  in  some  cases,  however,  is  not  indicated  by  any  pain  — a circum- 
stance which  is  owing,  no  doubt,  to  the  diminished  state  of  the  sensibility.  If 
the  abdomen  was  previously  tympanitic,  the  peritonitis  does  not  cause  it  to 
change  its  form  ; the  small  quantity  of  liquid  produced  is  not  then  easily  de- 
tected ; in  a word,  the  different  local  signs  of  peritonitis  may  be  but  very  im- 
perfectly marked  ; and  there  are  cases  where  the  sudden  increase  of  the  pros- 
tration, and  the  rapid  alteration  of  the  features,  have  been  the  only  additional 
symptoms  which  coincided  with  the  invasion  of  these  attacks  of  peritonitis 
produced  by  perforation. 

Speedy  death  commonly  follows  peritonitis,  which  comes  on,  in  the  progress 

* For  a description  of  these  perforations,  see  our  Pathological  Jlnatomy. 


144 


ANDRAL’S  MEDICAL  CLINIC. 


of  fever,  in  consequence  of  intestinal  perforation.  The  patients  may  die  from 
twelve  to  twenty  hours  after  the  appearance  of  the  first  signs  which  excite  any 
suspicion  of  this  affection  ; however,  it  may  happen  that  death  does  not  occur 
till  a considerably  later  period.  We  have  seen  a person  who  had  arrived  at 
one  of  the  last  stages  of  adynamic  fever,  when  all  at  once  vomiting  came  on, 
and  at  the  same  time  the  abdomen  became  tense  and  painful  on  pressure.  We 
supposed  that  one  of  the  ulcerations,  which  probably  existed  in  the  intestine, 
had  terminated  by  perforation.  However,  on  the  following  day  the  vomiting 
and  nausea  ceased ; the  abdomen,  when  pressed,  evinced  no  pain.  We  thought 
we  were  deceived.  The  patient  lived  three  or  four  days  more  without  the 
peritonitis  giving  any  new  indication  of  its  existence.  The  post-mortem  exami- 
nation, however,  proved  that  it  had  occurred,  and  that  it  had  been  occasioned 
by  intestinal  perforation.*  M.  Louis  has  mentioned  a case  wherein  death  did 
not  come  on  till  seven  days  after  the  development  of  the  first  symptoms  of 
peritonitis.  These  symptoms,  however,  had  set  in  in  a very  severe  form.  They 
became  somewhat  abated  towards  the  fourth  day. 

Intestinal  perforations  may  also  supervene  in  persons  who  as  yet  present  only 
symptoms  of  a very  slight  fever,  and  a disease  not  as  yet  marked  by  any  character 
of  severity  may  thus  be  suddenly  changed  into  a disease  rapidly  fatal. 

By  recapitulating  all  that  has  been  just  said  regarding  the  state  of  the  small 
intestine  in  persons  who  die  during  the  progress  of  a continued  fever,  we  shall 
lay  down  the  following  propositions  : — 

1.  Among  persons  who  die  with  one  or  other  of  the  morbid  groups  called 
essential  fevers,  some  present  no  appreciable  lesion  in  the  small  intestine. 

2.  In  others,  we  find  in  the  small  intestine  lesions  similar  to  those  found  in 
most  other  diseases  (injection,  softening  of  the  mucous  membrane  in  different 
stages,  etc.). 

3.  In  the  greater  number,  the  small  intestine  presents  a peculiar  lesion,  which, 
in  its  acute  form,  is  almost  exclusively  confined  to  what  are  called  essential 
fevers,  and  which  consists  in  inflammatory  tumefaction  of  the  intestinal  follicles. 
From  this  tumefaction  arises  an  exantheme  which  occupies  the  termination  of 
the  ileum. 

4.  This  exantheme  may  terminate  in  mere  resolution  or  in  ulceration. 

* The  perforations  which  occur  in  other  diseases  besides  fever,  though  ordinarily  followed 
by  peritonitis,  which  proves  rapidly  fatal,  may  sometimes  occasion  only  chronic  peritonitis. 
The  following  case  appears  very  remarkable  in  this  respect: — A young  man,  labouring  under 
pulmonary  phthisis,  had,  for  a considerable  time,  profuse  diarrhoea.  The  abdomen  had  been 
always  entirely  free  from  pain.  One  day  he  complained  of  acute  pain  around  the  umbilicus, 
which  was  increased  by  pressure.  This  pain  was  considered  as  the  result  of  inflammation  in 
the  digestive  tube.  It  remained  constant,  though  not  very  severe,  for  eight  or  ten  days. 
None  of  the  other  symptoms  were  much  aggravated.  The  patient  suddenly  perceived  his  ab- 
domen moistened  in  a great  quantity  of  liquid,  and  discovered  a linear  fissure  at  the  umbilicus. 
In  the  course  of  the  day  an  ascaris  lumbricoides  escaped  with  a yellow  fluid  similar  to  that 
usually  filling  the  small  intestines.  Was  it  not  reasonable  to  suppose  that  a portion  of  intes- 
tine had  been  perforated  ; that,  by  means  of  partial  adhesions,  contracted  between  it  and  the 
abdominal  parietes,  no  effusion  could  take  place  into  the  peritoneum,  and  that  the  abdominal 
parietes  were  in  their  turn  inflamed  and  perforated  1 Was  it  not,  in  a word,  a prseternatural 
anus  which  was  now  established  1 Still,  on  the  following  days,  a little  fluid  continued  to 
escape  through  the  fistula.  The  abdominal  pains  were  not  severe.  The  patient,  having  now 
arrived  at  the  last  stage  of  pulmonary  consumption,  died  twenty-seven  days  after  the  appear- 
ance of  the  first  pains,  and  about  eighteen  days  after  the  formation  of  the  fistula.  Traces  of  a 
frightful  peritonitis  were  found.  The  intestines  were  united  into  one  single  mass  by  black 
abd  very  thick  false  membranes.  Some  greenish  fluid  was  effused  between  the  convolutions 
of  the  intestines,  and  retained  there  by  membranous  bands,  which  formed,  as  it  were,  the 
parietes  of  a number  of  partial  cells.  No  adhesion  existed  at  the  umbilical  region.  Two 
ascarides  lumbricoides  were  found  in  the  peritoneum.  Their  presence  could  not  suffer  us  to 
doubt  the  existence  of  a perforation  of  the  intestine  ; but  the  adhesions  were  so  numerous  and 
so  close,  that  it  was  impossible  to  find  it. 


DISEASES  OF  THE  ABDOMEN.  I45 

5.  Observation  does  not  prove  that  every  exantheme  which  ulcerates  com- 
menced by  becoming  changed  into  an  eschar. 

6.  Ulcerations,  when  once  formed,  do  not  necessarily  prevent  recovery,  for 
we  have  several  times  ascertained  their  cicatrisation. 

7.  The  exantheme  does  not  seem  to  run  through  as  fixed  stages,  as  has  been 
stated,  in  its  development,  as  in  its  terminations.  When  once  produced,  it 
does  not  necessarily  terminate  either  in  gangrene  or  ulceration ; and  when  the 
latter  does  take  place,  it  is  not  always  after  the  same  lapse  of  time. 

c. — Large  Intestine. 

Its  lesions  are  far  from  being  uniform.  In  a considerable  number  of  our 
cases  we  found  it  perfectly  healthy  through  its  entire  extent. 

Of  the  different  parts  of  the  large  intestine  the  caecum  is  that  most  usually  the 
seat  of  lesion. 

The  morbid  changes  found  in  the  large  intestine  are : — 

1.  Simple  erythema,  which  is  very  rarely  general,  but  is  frequently  limited 
to  the  caecum. 

2.  Unusual  enlargement  of  the  follicles.  The  result  of  this  is  an  exantheme, 
which,  in  the  caecum,  may  present  itself  under  the  form  of  patches  similar  to 
those  of  the  small  intestine,  but  which,  over  the  remainder  of  the  large  intestine, 
is  never  seen  except  under  the  appearance  of  pustules  or  isolated  pimples 
(boutons). 

3.  Ulcerations.  These  go  on  diminishing  in  frequency  from  the  caecum  to- 
wards the  rectum.  Those  observed  in  the  caecum  have  the  same  appearance 
as  those  at  the  termination  of  the  small  intestine.  In  the  colon  they  are  gener- 
ally smaller,  and  separated  by  greater  intervals.  We  have  met  a case  in  which, 
of  the  different  parts  of  the  large  intestine,  the  reetum  alone  contained  ulcera- 
tions : they  were  all  of  the  same  form  and  same  size  ; one  would  have  readily 
taken  them  for  the  enlarged  orifices  of  follicles. 

Thus  the  lesions  found  in  the  large  intestine  are  of  the  same  nature  as  those 
found  in  the  small  intestine  ; as  the  latter,  they  may  be  divided  into  lesions 
similar  to  those  met  in  all  diseases  indifferently,  and  into  special  lesions. 

The  large  intestine  may,  like  the  small  intestine,  but  more  frequently  than  it, 
be  found  totally  exempt  from  any  change. 

d. — Substances  contained  in  the  digestive  tube. 

Worms. — These  we  have  met  in  only  a very  small  number  of  cases  ; they  were 
very  numerous  in  one  of  these  cases,  and  very  few  in  the  others.  They  were 
ascarides  lumbricoides,  and  tricocephali.  The  first  were  lodged  in  the  small 
intestine,  and  the  second  in  the  cascum.  It  seemed  to  us  that  in  the  different 
cases  where  we  met  them,  they  were  merely  an  accidental  complication  of  the 
disease.  They  coincided  with  most  of  the  symptoms  characterizing  mucous 
fever  in  the  subject  of  our  fourth  case.  It  may  be  well  to  mention  here,  that 
in  most  of  those  who  died  of  the  epidemic  mucous  fever  of  Gottingen,  Raederer 
and  Wagler  found  a great  number  of  worms  in  the  intestines.  Why  were 
these  animals  produced  in  such  quantity  in  this  epidemic?  Why  in  the  post- 
mortem examinations  in  Paris  for  several  years  back  have  so  few  worms  been 
found  ?* 

Liquid  substances. — We  have  nothing  particular  to  observe  with  respect  to 
the  mucus  found  in  the  intestines  of  persons  who  die  during  the  course  of  con- 

* In  several  other  epidemics  of  typhoid  fevers,  entirely  resembling  dothinenteritc  in  their 
* symptoms,  which  have  afflicted  Europe  during  the  sixteenth,  seventeenth,  and  eighteenth 
centuries,  the  very  great  quantity  of  worms  passed  by  the  patients  was  noticed  as  a very  pre- 
vailing phenomenon  of  these  epidemics. 

13 


146 


ANDltAL’S  MEDICAL  CLINIC. 


tinued  fever.  In  its  place  there  is  often  found  a liquid  matter,  resembling 
water  coloured  yellow,  which  fills  a part  of  the  digestive  tube.  There  are 
some  cases  in  which  the  intestine  contains  a great  quantity  of  yellow,  greenish, 
or  reddish  bile,  which  tinges  its  inner  surface.  We  very  rarely  found  this  bile 
in  the  stomach  ; and,  in  general,  what  we  have  observed  in  this  respect  does 
not  induce  us  to  admit  that  the  accumulation  of  bile  in  the  digestive  passages 
acts  a considerable  part  in  the  production  of  fevers,  and  consequently  should 
not  afford  any  indication  for  the  treatment.  We  have  not  found  more  bile  than 
usual  in  the  digestive  tube  of  a person  who  died  whilst  he  as  yet  presented 
only  the  symptoms  of  a bilious  fever  (Case  1). 

We  sometimes  find  blood  exhaled  on  the  surface  of  the  stomach  or  of  the 
intestines.  This  blood  is  sometimes  liquid,  sometimes  coagulated.  There  are 
some  cases  where  there  is  but  a small  quantity  of  it  deposited  in  some  points 
•of  the  digestive  tube ; in  other  cases  this  tube  is  filled  with  it,  and  death  has 
then  been  the  result  of  gastric  or  intestinal  hemorrhage.  This  hemorrhage  is 
not  connected  with  any  particular  lesion  of  the  mucous  membrane,  which,  be- 
neath the  blood,  presents  only  redness,  ecchymoses,  different  degrees  of  soften- 
ing, and  which,  in  the  intestine,  presents  only  those  same  alterations,  or  else 
traces  either  of  exanthemes  or  of  ulcerations  ; we  do  not  find  the  cause  of  the 
hemorrhage  in  the  solution  of  continuity  of  any  large  vessel. 

Modified  by  its  tarrying  in  the  stomach,  the  blood,  which  is  accumulated  in 
it,  assumes  occasionally  such  an  appearance,  that  it  becomes  entirely  similar  to 
the  black  fluid  which  constitutes  the  matter  of  vomiting  in  the  yellow  fever. 
We  have  cited  a case  of  this  kind  ; M.  Bouillaud  has  detailed  another  in  which 
there  was  at  the  same  time  a yellow  tinge  of  the  skin,  and  the  patient  had  passed 
blood  both  by  vomiting  and  purging.  There  was  found  in  the  stomach  a brown 
liquid  resembling  a concentrated  decoction  of  coffee.  The  gastric  mucous 
membrane  presented  towards  the  great  cul-de-sac  patches  of  a vinous  red  colour, 
similar  to  ecchymoses.  In  the  duodenum  there  was  nothing  but  bile  ; but  in 
the  remainder  of  the  small  intestine  some  blood  was  collected,  which  was 
coagulated  in  some  points  and  liquid  in  others.  Several  abscesses  were  found 
in  the  liver. 

Gas.  — The  colon  is  the  part  of  the  digestive  tube  wherein  a great  quantity 
of  gas  is  most  frequently  found  in  persons  who  have  died  of  a bad  fever.  In 
many  individuals  the  colon  is  so  very  much  distended  with  gases,  that  it  is 
.distinctly  marked  through  the  abdominal  parietes,  presses  the  diaphragm  up- 
wards, and  conceals  in  a great  measure  the  remainder  of  the  digestive  tube,  and 
the  other  abdominal  viscera.  It  occupies  the  epigastrium  in  particular,  where, 
during  life,  it  might  be  taken  for  the  stomach. 

The  cause,  under  whose  influence  this  great  disengagement  of  gas  takes 
place  in  the  colon,  is  still  unknown.  We  cannot  attribute  it  to  inflammation, 
nor  ulceration  of  the  colon,  for  this  meteorism  exists  as  often  in  cases  where, 
after  death,  the  colon  is  found  free  from  all  appreciable  lesion,  as  in  those  where 
it  is  found  diseased.  Besides,  as  has  been  remarked  by  M.  Louis,  the  small 
intestine  is  mueh  more  frequently  inflamed  or  ulcerated  than  the  colon,  and  yet 
there  is  not  produced  in  the  ileum  the  same  quantity  of  gas  as  in  the  large  in- 
testine. All  we  can  say  is,  that  this  great  disengagement  of  gas  belongs  almost 
exclusively  to  the  class  of  diseases  now  under  consideration. 

d. — Relation  which  the  Gastro-intestinal  Lesions  bear  to  the  Symptoms. 

After  having  passed  in  review  the  different  morbid'  changes  found  in  the 
digestive  tube  of  persons  who  have  died  during  the  progress  of  continued  fever, 
we  must  now  inquire  what  relation  may  be  established  : 1st,  between  the  period 
at  which  these  changes  come  on,  and  the  different  phases  of  the  diseases  ; 2dly, 
between  the  intensity  of  these  same  changes,  and  the  severity  of  the  symptoms. 


DISEASES  OF  THE  ABDOMEN. 


147 


The  solution  of  these  two  questions  once  given,  we  shall  be  better  able  to  ap- 
preciate the  influence  exercised  by  the  gastro-intestinal  affection  on  the  produc- 
tion of  the  symptoms. 

The  second  case  afforded  us  an  instance  of  an  individual  who  died  in  only 
six  days  after  the  invasion  of  the  disease.  In  this  case  the  alteration  of  the 
follicles  was  very  well  marked.  It  was  equally  so  in  another  (Case  1),  who 
died  on  the  ninth  day.  M.  Trousseau  mentions  a post-mortem  examination  by 
Bretonneau,  on  the  fifth  day  of  the  fever.  In  this  case,  as  in  the  two  preceding, 
the  follicles  were  found  diseased. 

The  glands  of  Peyer  were  very  much  tumefied,  and  they  formed  patches 
which  were  raised  above  the  mucous  membrane.  MM,  Petit  and  Serres  have 
mentioned  the  case  of  a man  who  died  of  pneumonia  a very  few  days  after  the 
signs  of  the  disease,  which  they  called  entero-mesenteric  fever,  began  to  mani- 
fest themselves  (from  the  fourth  to  the  sixth  day)  ; the  patches  of  the  ileum 
were  very  numerous.  They  were  also  met  by  M.  Louis  on  the  eighth  day  of 
the  disease. 

Thus  when  the  continued  fever  is  connected  with  the  intestinal  exantheme, 
the  latter  commences  from  the  very  first  appearance  of  the  disease.  It  also 
accompanies  it  in  its  entire  course,  and  it  is  found  in  fevers  which  have  lasted 
only  a very  few  days,  as  well  as  in  fevers  which  have  not  been  followed  by 
death  till  after  forty  or  fifty  days’  duration  of  the  affection.  This  second  state- 
ment is  sufficiently  demonstrated  by  our  particular  cases,  as  also  by  those  of 
MM.  Petit  and  Serres,  Bretonneau,  and  Louis. 

When  the  group  of  symptoms  which  constituted  the  fever  has  disappeared, 
and  when  at  a period  more  or  less  remote  from  the  commencement  of  conva- 
lescence some  other  affection  carries  off  the  patient,  traces  of  cure  of  the  exan- 
theme  are  found  in  the  intestines  ; these  traces  are  either  depressed  patches,  or 
cicatrised  ulcerations.  Sometimes  even  the  dothinenterite  still  exists,  though 
the  fever  may  have  decreased  for  some  days  back ; we  then  find  either  patches 
whose  resolution  is  scarcely  commencing,  or  ulcerations  not  yet  cicatrised. 
Thus,  when  a lung  has  been  attacked  with  inflammation,  it  often  happens  that 
it  still  remains  hepatised  after  the  characteristic  symptoms  of  the  disease  have 
disappeared. 

Thus  inflammation  of  the  follicles  arises  with  the  fever,  or  at  least  a little 
time  after  it,  and  it  continues  as  long  as  the  fever  itself  continues.  To  be  sure, 
the  intensity  of  the  lesions  which  characterize  follicular  enteritis  is  not  always 
proportioned  to  the  severity  of  the  symptoms  observed  during  life.  But  is  not  this 
the  case  with  most  diseases  where,  in  different  subjects,  symptoms  varying  both 
in  their  nature  and  severity  appear  in  consequence  of  one  and  the  same  lesion  ? 

Follicular  enteritis  then  appears  to  us  to  be  the  commencement  of  a very 
great  number  of  what  are  called  essential  fevers,  and  particularly  of  that  which 
MM.  Chomel  and  Louis  have  designated  typhoid  fever. 

This  latter  fever  itself  may,  however,  present  itself  in  cases  where  the  intestinal 
follicles  are  not  diseased,  and,  in  a word,  there  is  scarcely  any  disease,  having  its 
primary  seat  either  in  the  solids  or  in  the  blood,  in  consequence  of  which  we  may 
not  see  typhoid  fever  sometimes  developed,  and  much  more  frequently  simple 
typhoid  phenomena , or  under  other  forms  the  different  symptoms  to  which  Pinel 
gave  the  name  of  ataxic  and  adynamic.  Our  particular  cases  present  numerous 
instances  of  this  ; and  the  reflections  accompanying  them  sufficiently  develop  this 
point  of  doctrine. 


SECTION  I. 

FUNCTIONAL  LESIONS  OF  THE  DIGESTIVE  APPARATUS,  OBSERVED  DURING 

LIFE. 

This  apparatus  presents,  during  the  progress  of  fever,  disturbances  of  func- 


148 


ANDUAL’S  MEDICAL  CLINIC. 


tions  which  tend  to  show,  at  least  as  much  as  the  lesions  detected  there  after 
death,  the  important  part  it  performs  in  the  production  of  these  diseases. 

Let  us  examine  those  functional  disturbances,  referring  them  to  the  different 
parts  of  the  canal,  where  we  may  presume  that  each  of  them  has  its  seat. 

In  almost  all  the  cases  of  slightor  severe  fevers  reported  in  this  work,  we  found 
the  mucous  membrane  of  the  mouth,  excepting  that  of  the  tongue,  of  which  we 
shall  speak  presently,  changed  both  with  respect  to  the  quantity  of  blood  which 
should  circulate  through  it,  as  also  with  respect  to  the  secretion  which  in  the 
natural  state  should  take  place  on  its  surface. 

The  mucous  membrane  of  the  mouth,  in  these  diseases,  is  usually  of  a deeper 
red  than  in  other  affections  where  the  febrile  disturbance  is  still  as  great;  as,  for 
instance,  in  acute  pneumonia  or  acute  articular  rheumatism.  At  the  same  time 
its  secretion  is  either  suppressed,  or  increased  in  quantity,  or  changed  in  cha- 
racter. In  the  first  case,  this  membrane  presents  unusual  dryness ; in  the 
second  case,  the  mouth  is  filled  with  a viscid,  gluey  mucus  ; in  the  third  case, 
instead  of  mucus,  there  is  sometimes  observed  on  the  surface  of  the  lips,  gums, 
and  cheeks,  a creamy  or  cheesy  substance  which  covers  these  parts,  either  under 
the  form  of  isolated  points,  or  in  the  form  of  patches  of  greater  or  smaller  size. 
At  other  times  the  mucous  membrane  exhales  a certain  quantity  of  blood, 
which  coagulates  on  its  surface,  and  produces  yellow  or  black  crusts  more  or  less 
thick. 

What  do  these  different  modifications  of  the  buccal  secretion  indicate?  And 
first,  are  they  connected  with  certain  determinate  and  always  identical  states 
-of  the  sub-diaphragmatic  portion  of  the  digestive  canal  ? By  no  means.  All 
these  varieties  of  the  buccal  secretion  are  found  without  there  being  any  differ- 
ence in  the  morbid  changes  of  the  stomach  or  intestines.  Still  more  ; there  is 
not  one  of  these  varieties  connected  with  certain  degrees  of  intensity  of  the  gas- 
tro-intestinal  lesion.  The  latter  may  be  very  slight,  or  very  severe,  with  all  the 
possible  shades  of  secretion  of  the  mucous  membrane  of  the  mouth.  These 
shades  depend,  then,  on  the  gastro-intestinal  affection  with  which  they  coincide, 
and  which  is,  as  some  will  have  it,  their  occasional  cause,  but  on  peculiar  dis- 
positions of  the  individuals,  dispositions  which  are  always  connected  with  the 
states  in  which  their  innervation  and  hematosis  may  be  placed,  whether  tempo- 
rarily or  permanently. 

Thus,  then,  the  modifications  which  the  mucous  membrane  of  the  mouth  pre- 
sents in  persons  labouring  under  continued  fever,  do  not  indicate  the  nature  or 
severity  of  the  lesion  of  the  digestive  passages  ; they  are  but  the  expression  of 
a general  state  by  which  the  prognosis  of  the  disease  and  its  treatment  should 
be  regulated. 

Of  all  diseases,  fevers  are  certainly  those  where  the  tongue  presents  the  most 
varied  as  well  as  the  most  important  modifications.  These  modifications  are  so 
generally  known,  and  we  have  dwelt  so  much  oil  them  in  our  particular  cases, 
that  we  shall  not  now  lose  much  time  in  describing  them.  We  shall  now  speak 
of  them  principally  in  order  to  convert  them  into  signs. 

Is  the  state  of  the  tongue,  in  fevers,  a faithful  index  of  the  state  of  the  stomach  ? 
From  the  facts  contained  in  our  particular  cases,  we  feel  warranted  in  deducing 
the  following  conclusions: 

1.  No  constant  relation  can  be  established  between  the  state  of  the  tongue 
and  that  of  the  stomach. 

2.  Each  of  the  modifications  which  the  tongue  may  present,  in  its  colour 
and  in  its  coatings,  does  not  correspond  with  any  specific  modification  of  the 
stomach. 

3.  The  stomach  may  present  after  death  a similar  state,  however  dissimilar 
may  have  been  the  state  of  the  tongue  during  life. 

4.  A morbid  state  of  the  stomach  may  coincide  with  a natural  state  of  the 


DISEASES  OF  THE  ABDOMEN. 


149 


tongue,  and  a morbid  state  of  the  tongue  may  coincide  with  a natural  state  of  the 
stomach. 

5.  The  dryness  and  black  colour  of  the  tongue  does  not  indicate  a more  se- 
vere affection  of  the  stomach  than  is  indicated  by  any  other  modification  of  the 
tongue. 

These  results  have  been  still  further  confirmed  by  the  observations  ofM.  Louis. 
We  may  also  remark  with  this  physician,  that  in  a great  number  of  other  cases 
besides  continued  fevers,  where  the  tongue  scarcely  deviates  from  its  natural  state, 
the  stomach  is  not  found  in  a state  different  from  that  in  which  it  is  found  where 
the  tongue  is  red,  dry,  covered  with  black  crusts,  &c. 

Can  we  establish  a closer  connexion  between  the  state  of  the  tongue  and  the 
state  of  the  small  intestine  ? 

With  the  exception  of  some  individuals  whose  tongue  continued  natural,  we 
found  it  changed  in  all  those  whose  small  intestine  was  exanthematous.  But 
whether  the  patches  were  still  intact,  or  already  in  a state  of  ulceration,  there 
was  no  state  of  the  tongue  which  corresponded  exactly  with  either  of  these 
stages  of  the  exantheme.  And  further,  the  varieties  in  the  extent  of  this  exan- 
theme  were  not  indicated  by  different  states  of  the  tongue  ; neither  could  it  serve 
to  show  whether,  between  the  patches  or  between  the  ulcerations,  the  mucous 
membrane  was  healthy  or  diseased.  Thus,  of  two  individuals  who  were  both 
found  to  have  dothinenterite  similar  in  every  respect,  the  one  had  his  tongue 
covered  with  a yellowish  coat,  whilst  the  tongue  of  the  other  was  dark-co- 
loured. 

Among  the  individuals  who,  after  having  had  all  the  symptoms  of  severe  fever, 
yet  presented  no  trace  of  exantheme,  but  simple  erytheme  of  the  intestinal  mucous 
membrane,  some  retained  a natural  state  of  the  tongue,  whilst  others  had  it  dry 
and  black  ; and  yet  these  different  states  of  the  tongue  existed  with  one  and  the 
same  state  of  the  small  intestine. 

Again,  in  those  in  whom  the  symptoms  of  bad  fever  could  not  be  accounted 
for  by  any  lesion  of  the  digestive  passages,  we  found  the  tongue  dry  and  black, 
with  all  the  small  intestine  perfectly  healthy. 

There  is  not,  therefore,  any  more  necessary  connexion  between  the  state  of 
the  small  intestine  and  of  the  tongue,  than  between  that  of  the  tongue  and  the 
stomach. 

With  respect  to  the  large  intestine,  we  have  often  found  it  perfectly  healthy 
with  all  possible  states  of  the  tongue. 

It  seems  to  us,  therefore,  sufficiently  demonstrated,  that  of  the  numerous 
modifications  which  the  tongue  may  undergo,  there  is  not  one  which  should  be 
considered  as  the  necessary  product  of  a morbid  state  of  the  stomach  or  intes- 
tines. The  tongue  may  remain  healthy,  the  digestive  tube  being  diseased  ; it 
may  present  a diseased  appearance,  though  the  digestive  tube  may  have  continued 
healthy  ; but  there  is  very  often  a coincidence  between  the  affection  of  the  tongue 
and  of  the  sub-diaphragmatic  portion  of  the  digestive  passages,  which  may  be 
accounted  for  by  the  similarity  of  the  organization  and  functions  of  these  differ- 
ent parts.  The  same  cause,  which,  from  the  commencement  of  a continued 
fever,  or  in  its  progress,  renders  the  gastro-intestinal  mucous  membrane  dis- 
eased, also  attacks  the  mucous  membrane  of  the  tongue  and  mouth,  as  it  almost 
always  attacks  the  mucous  membrane  of  the  air  passages  at  the  same  time  ; but 
it  may  happen,  as  is  proved  by  observation,  that  this  cause  produces  the  disease 
in  only  one  of  these  parts,  leaving  the  others  intact.  Only  taking  into  account 
how  very  rarely  these  affections  exist  separately,  and  considering  their  frequent 
coincidence,  we  must  admit,  that  every  time  there  is  any  modification  in  the  state 
of  the  tongue,  there  are  strong  grounds  for  thinking  that  there  must  be  at  the 
same  time  disease  of  the  gastro-intestinal  mucous  membrane  ; it  is  from  the 
13* 


150 


AN  ORAL’S  MEDICAL  CLINIC. 


other  symptoms  vve  are  to  learn  whether  this  coincidence,  which  is  only  possi- 
ble, but  not  necessary,  does  really  occur  in  such  or  such  a particular  case. 

With  respect  to  the  varieties  of  changes  which  the  tongue  undergoes,  with 
what  are  we  to  connect  them  ? We  now  know  it  is  not  with  different  morbid 
states  of  the  gastro-intestinal  mucous  membrane,  such  at  least  as  those  presented 
to  us  in  post-mortem  examinations.  Here  all  our  theories  have  proved  insuffi- 
cient to  explain  these  every-day  facts.  But  observation  has  taught  us,  that 
among  these  numerous  modifications  of  the  tongue,  there  are  several  which, 
connected  or  not  with  an  affection  of  the  stomach  or  of  the  intestines,  indicate 
certain  specific  states  of  the  system  which  can  only  be  combated  with  advantage 
by  opposing  to  them  a treatment  as  specific  as  themselves.*  Thus,  a red  tongue, 
whether  this  redness  appears  in  separate  and  isolated  points,  or  on  the  edges,  at 
its  apex,  or  at  its  centre,  uniformly  contraindicates  the  employment  of  any 
other  means  than  that  of  antiphlogistics  ; and  a broad  tongue,  covered  with  a 
white  or  yellowish  coat,  and  without  any  trace  of  redness,  whether  pointed,  or 
of  any  other  kind,  often  contraindicates  bloodletting  : it  may  indicate,  on  the 
contrary,  the  employment  of  emetics  or  purgatives  ; and  that,  not  because  there 
is  then  in  the  stomach  matters  to  be  evacuated,  but  because  experience  has 
shown  us  that,  after  the  changes  produced  in  the  system  by  strong  emetics  or 
purgatives,  there  is  the  greatest  possible  chance  for  our  seeing  that  peculiar 
morbid  state  to  disappear,  which  had  been  indicated  by  the  appearance  of  the 
tongue  ; but  it  should  be  well  observed,  that  in  the  same  manner  as  redness  of 
the  tongue  is  not  necessarily  connected  with  gastric  irritation,  so  whiteness  of 
the  tongue  does  not  always  exclude  the  existence  of  this  irritation  : it  is  for  the 
other  symptoms  to  disclose  this  ; we  may  then  estimate  their  importance,  and 
calculate  how  far  the  existence  of  this  irritation  may  modify  the  treatment. 
Whilst  we  no  longer  consider  dryness  and  blackness  of  the  tongue  as  neces- 
sarily connected  with  gastro-intestinal  inflammation,  we  shall  find  in  this  ap- 
pearance of  the  tongue  the  index  of  a third  state  of  the  system,  in  which,  whe- 
ther there  may  be  or  may  not  be  gastro-enterite,  debilitating  means  of  every 
kind  become  injurious  ; by  which  we  do  not  mean  to  say  that  we  must  neces- 
sarily have  recourse  to  a stimulant  plan  of  treatment ; to  refrain  from  bleeding 
does  not  imply  that  we  are  to  give  quinquina.  To  leave  to  nature,  by  an  ex- 
pectant mode  of  treatment,  sufficient  strength,  so  that  she  may  be  able  to  proceed 
to  a resolution  of  the  disease,  is  not  the  same  thing  as  occasioning  by  medicine 
a reaction  entirely  artificial,  which  may  be  occasionally  useful,  but  is  also  fre- 
quently unattended  with  benefit,  or  proves  even  injurious. 

Dryness  and  blackness  of  the  tongue  do  not  ordinarily  happen  till  rather  an 
advanced  stage  of  the  disease.  This  state  of  the  tongue  may  be  preceded  by  a 
red  and  polished  appearance  ; oftentimes  the  tongue  then  seems  to  be  glued  to 
the  finger  which  touches  it.  The  epithelium  becomes  still  drier;  it  then  be- 
comes chopped  ; blood  escapes  from  these  chops  ; it  accumulates  on  the  surface 
of  the  tongue,  where  it  forms  brown  or  black  crusts. 

At  other  times,  a viscid  mucus  of  a dirty  grey  colour  causes  the  tongue  to 
adhere  to  the  velum  palati  and  to  the  teeth.  This  mucus  is  imperceptibly 
changed  into  a blackish  coat. 

In  other  persons,  the  white  yellow  coat  which  covered  the  tongue  is  observed 
gradually  to  become  brown. 

In  other  cases,  this  coat  which  is  at  first  very  thick,  diminishes  ; it  disap- 
pears from  the  centre  of  the  tongue,  which  at  this  point  becomes  dry,  and  pre- 
sents a red  tint,  which  passes  imperceptibly  to  brown  and  black. 

* We  should  never  forget  that,  at  the  moment  a disease  attacks  a patient,  a certain  modifi- 
cation occurs  in  the  organization,  the  nature  of  which  depends  on  the  different  physiological 
states  in  which  the  disease  finds  the  subject,  the  result  of  which  may  be  a difference  in  the 
pature  of  this  disease  itself,  the  appreciable  lesions  of  the  organs  remaining  the  same. 


DISEASES  OP  THE  ABDOMEN.  151 

Beneath  the  black  crusts,  or  between  them,  the  tongue  is  sometimes  remark- 
ably pale. 

At  the  same  time  that  it  is  dry  it  may  be  very  pale,  or  of  a clear  yellow  tint, 
which  somewhat  resembles  the  colour  of  burnt  cream. 

Though,  as  we  have  just  now  remarked,  the  dry  and  fuliginous  state  of  the 
tongue  does  not  in  general  present  itself  till  after  the  disease  has  existed  for 
some  time,  there  are  some  cases  where  this  state  of  the  tongue  shows  itself 
from  the  very  first  days,  or  even  from  the  very  first  moment.  Sometimes  the 
premature  appearance  of  this  state  coincides  with  other  bad  symptoms,  which 
may  continue  or  disappear  before  it.  Sometimes  no  other  alarming  phenome- 
non is  observed  than  the  dryness  and  brown  colour  of  the  tongue.  There  are 
some  persons  who  are  very  particularly  disposed  in'  this  respect ; they  cannot 
have  even  a slight  attack  of  illness,  without  their  tongue  becoming  instantly  dry 
and  brown.' * In  some,  this  state  of  the  tongue  continues  during  the  entire 
course  of  the  disease  ; in  other  persons  it  only  marks  its  commencement.  We 
have  mentioned  some  cases  of  this  kind.  Thus  the  prognostics  drawn  from  the 
tongue  have  their  exceptions  as  well  as  others. 

Let  us  novy  follow  up  the  examination  of  the  other  functional  disturbances  of 
the  digestive  tube. 

The  loss  of  appetite  has  constituted,  in  several  patients,  the  precursor  of  the 
affection.  A certain  time  before  taking  to  their  bed  — sometimes  for  some  days 
only,  sometimes  for  a month  or  six  weeks  — they  no  longer  felt  the  sensation 
of  hunger  as  usual,  and  this  sensation  by  little  and  little  became  altogether  lost. 
This  was  occasionally  the  only  derangement  which  they  suffered  in  their 
health  ; but  most  frequently  to  the  diminution  of  appetite  there  was  added 
general  illness,  a distressing  headach,  pains  iy  the  kidneys  and  in  the  limbs. 

In  several  other  patients,  the  appetite  remained  intact  up  to  the  day  when 
they  were  suddenly  siezed  with  fever,  and  took  to  their  bed.  In  some  even  it 
was  almost  immediately  after  a meal  which  they  had  eaten  with  as  much  appe- 
tite as  usual  that  the  fever  manifested  itself. 

Anorexia  then  is  a frequent,  but  not  uniform,  precursor  of  continued  fever. 

During  the  entire  course  of  the  disease,  no  appetite  whatever  was  felt ; some 
patients  asked  for  food,  conceiving  the  debility  which  they  experienced  to  be 
hunger. 

At  a subsequent  period,  when  every  thing  indicates  the  commencement  of 
convalescence,  there  are  some  patients  in  whom  the  appetite  is  suddenly  re- 
established, and  a considerable  number  of  persons  may  pass  at  once  from  a strict 
to  a very  substantial  diet : we  do  not  think  that  such  would  have  been  the  case, 
if  there  were  in  such  persons  any  serious  lesion  of  the  gastric  mucous  mem- 
brane. Others,  though  feeling  considerable  appetite,  cannot  satisfy  it  without 
risk  ; when  a small  portion  of  food  is  given  to  them,  the  pulse  becomes  acceler- 
ated, the  skin  hot,  or  diarrhoea  returns.  And  yet  there  is  no  bad  taste  in  the 
mouth,  the  tongue  is  natural,  there  is  no  thirst,  and  the  epigastrium  is  free  from 
pain.  We  are  inclined  to  think,  that  in  such  a case  it  is  not  the  stomach  which 
suffers  from  the  food,  but  the  intestines,  whose  mucous  membrane,  as  yet 
scarcely  healed,  is  irritated  by  the  contact  of  any  foreign  substance.  For  want 
of  paying  sufficient  attention  in  such  cases  to  the  effects  of  taking  food,  persons 
have  been  attacked  with  diarrhoea  which  nothing  could  check,  and  which  car- 
ried them  to  the  grave,  either  in  an  acute  form,  or  after  having  made  them  pass 
slowly  through  all  the  stages  of  marasmus. 

With  such  convalescents  it  is  important,  therefore,  for  some  time  to  restrict 
their  diet  to,  food,  the  materials  of  which,  being  almost  entirely  absorbed  in  the 

* We  have  remarked  that  the  tongue  became  dry  and  brown  in  old  persons  more  readily 
than  at  the  other  periods  of  life. 


152 


ANDItAL’S  MEDICAL  CLINIC. 


stomach  itself,  or  in  the  upper  part  of  the  small  intestine,  afford  the  least  possible 
residue.  In  such  cases,  we  have  seen  milk  replaced  with  great  benefit  by  beef 
soup  suitably  prepared. 

In  other  convalescents,  all  their  functions  are  restored  to  the  normal  state  ; the 
diarrhoea  has  disappeared  for  a considerable  time,  and  yet  the  mouth  continues 
foul  and  clammy,  the  tongue  is  loaded,  and  the  appetite  is  not  restored.  Under 
such  circumstances,  a continuation  of  strict  regimen  is  all  that  is  to  be  prescribed. 
But  it  must  be  recollected  that  there  are  individuals  of  such  a constitution  that 
they  are  not  able  to  support  abstinence  from  all  food  for  a long  time  ; such  treat- 
ment in  them  gives  rise  to  various  nervous  symptoms,  an  alarming  acceleration 
of  the  circulation,  then  secondary  hyperemias,  the  real  cause  of  which  is  often 
overlooked.  In  such  cases  we  should  carefully  examine  the  state  of  the  primae 
vise,  and  if  there  appears  no  contraindication,  we  should  give  some  bitters. 
There  is  not  a doubt  but  the  adoption  of  this  treatment  has  often  produced  a 
most  favourable  change  in  the  state  of  the  stomach,  so  that  the  result  of  it  was 
the  return  of  appetite  ; and,  at  the  same  time,  all  the  symptoms  disappeared 
which  had  been  produced  and  kept  up  by  the  continued  strict  regimen.  Are 
these  cases  where  advantage  might  be  derived  from  the -use  of  emeto-cathartics, 
which  anqient  humourists  thought  themselves  in  a manner  bound  to  employ 
during  convalescence  in  almost  every  acute  disease?  Was  it  mere  theory 
which  suggested  this  practice  to  them  ? Was  it  the  observation  of  some  cases, 
wherein,  when  judiciously  applied,  it  had  succeeded?  With  respect  to  this 
matter,  it  should  be  recollected,  that  the  subjects  of  several  of  our  cases  were 
persons  having  no  longer  any  fever,  and  presenting  no  other  ailments  except 
want  of  appetite,  and  some  other  symptoms  referrible  to  gastric  disturbance, 
when  these  symptoms  began  to  c^sappear  immediately  after  they  had  taken  an 
emetic.  Satisfied  as  we  are  that  a question  of  therapeutics  especially  cannot 
be  solved  except  by  a much  greater  number  of  facts  than  those  we  have  given 
on  this  particular  point,  we  shall  merely  state  what  we  have  observed,  and, 
without  wishing  to  draw  from  it  any  definite  consequence,  we  still  think  such 
facts  merit  attention. 

The  sensation  of  thirst  has  been  very  variable  in  our  patients.  With  the  same 
group  of  symptoms,  some  experienced  intense  thirst,  whilst  others  felt  no  de- 
sire for  drink.  One  of  those  in  whom  the  thirst  was  extreme,  had  his  stomach 
perfectly  healthy.  Thirst,  therefore,  is  not  always  the  sign  of  gastric  irritation  : 
it  may  also  be  attributed  either  to  a derangement  of  all  the  functions  of  nutri- 
tion, or  to  a sudden  and  great  loss  of  the  serum  of  the  blood,  or  to  mere  disturb- 
ance of  the  nervous  system. 

A small  number  of  patients  experienced  nausea,  and  a still  smaller  number 
had  vomiting.  We  have  more  than  once  seen  this  symptom  make  its  appear- 
ance only  at  the  commencement  of  the  disease,  and  then  cease.  The  matters 
vomited  consisted  either  of  the  drinks  taken  into  the  stomach,  or  of  a small  quan- 
tity of  clear,  transparent  mucus,  or  of  yellow  or  greenish  bile,  or  of  blood.  This 
last  species  was  the  most  uncommon  ; the  blood  vomited  was  black,  like  a solu- 
tion of  chocolate  or  coffee-grounds. 

No  connexion  could  be  established  between  the  existence  of  nausea  or  vomit- 
ing and  any  determinate  state  of  the  stomach  appreciable  on  the  dead  body. 
On  the  one  hand,  we  have  not  observed  these  two  phenomena  in  several  per- 
sons whose  stomach  was  found  intensely  red  and  very  seriously  altered  ; on 
the  other  hand,  they  have  been  observed  in  persons  whose  stomach,  when  exa- 
mined after  death,  was  found  in  an  almost  healthy  state.  This  important  fact 
has  been  also  confirmed  by  M.  Louis.  Out  of  twenty  persons  labouring  under 
the  affection  which  he  has  called  typhoid  fever,  and  who  had  had  either  nausea 
or  vomiting,  only  eleven  presented  a more  or  less  serious  alteration  of  the  gas- 
tric mucous  membrane. 


DISEASES  OF  THE  ABDOMEN. 


153 


Thus  the  existence  of  nausea  or  vomiting  in  continued  fevers  does  not  prove 
that  there  is,  in  the  individuals  so  affected,  a greater  irritation  of  the  stomach  than 
in  those  in  whom  they  are  absent.  We  cannot  even  infer  from  them  the  simple 
fact  of  the  existence  of  this  irritation. 

What,  then,  is  indicated  by  these  phenomena  with  respect  to  the  nature  of 
the  disease  ?'  and  what  with  respect  to  treatment  ? 

What  appears  to  us  clearly  demonstrated  is  this,  that  when  an  individual 
labouring  under  continued  fever  happens  to  be  seized  with  vomiting,  without 
the  tongue  becoming  red,  without  having  thirst,  or  feeling  any  pain  in  the 
epigastrium,  there  is  reason  for  thinking  that  it  is  not  an  increase  of  gastric 
irritation  which  has  produced  this  vomiting.  Neither  do  we  think  that  it 
should  be  admitted  without  further  proof  that  this  nausea  and  vomiting,  which 
depend  not  on  gastric  irritation,  are  to  be  attributed  to  the  presence  of  bile,  or 
mucus  in  the  stomach,  or  to  what  Stoll  called  gastric  saburrse.  For,  in  such 
cases,  pathological  anatomy  has  no  more  proved  the  existence  of  such  saburrse, 
than  it  has  proved  the  stomach  to  be  invariably  red  or  softened.  It  is  easier, 
then,  to  point  out  the  circumstances  to  which  this  nausea  or  vomiting  cannot 
be  referred,  than  to  mark  the  organic  conditions  which  give  rise  to  them.  Do 
these  phenomena  depend  on  a disturbance  of  the  innervation?  We  would  be 
disposed  to  think  so  in  a certain  number  of  cases.  May  they  also  depend  on 
a necessity  felt  by  the  system  to  modify,  by  the  act  of  vomiting,  either  the 
secretion  of  the  mucous  follicles,  or  that  of  the  liver,  in  order  that  the  blood 
may  then  free  itself  from  the  principles  which  change  its  composition,  either 
by  their  quantity  or  their  qualities?  This  hypothesis  might  be  supported  by 
some  facts.  We  might  appeal,  in  its  defence,  to  those  well  authenticated  cases, 
in  which  persons  presenting  yellowness  of  the  skin,  foul  tongue,  constant 
nausea,  or  vomiting,  and,  at  the  same  time,  either  having  or  not  having  fever, 
have  been  promptly  freed  from  these  symptoms  after  taking  tartar  emetic. 
Some  of  the  cases  detailed  by  us  attest  the  truth  of  this  remark. 

To  the  facts  of  this  kind  already  cited  we  shall  add  the  following  : 

During  the  wet  summer  of  1829  several  patients  were  seen  by  us  to  present 
the  following  state  : — 

After  having  experienced,  for  some  days,  general  illness,  headach,  progressive 
diminution  of  appetite,  those  persons  lost  their  strength  ; their  countenance  as- 
sumed a yellowish  tint,  in  which  the  conjunctiva  also  participated  ; a thick  coat 
of  a yellow,  green,  or  white  colour,  covered  the  tongue,  which  was  broad,  and  not 
red  in  any  One  point  of  its  surface  ; at  first  there  was  a bad  taste  in  the  mouth, 
then  came  on  an  inclination  to  vomit,  and  ultimately  vomitingof  mucous  orbilious 
matter  ; several  could  not  take  the  smallest  quantity  of  ptisan  into  the  stomach 
without  instantly  rejecting  it ; an  annoying  sensation  of  weight  was  experienced 
in  the  epigastrium  ; the  abdomen,  in  every  other  part,  was  free  from  pain,  and 
soft,  sometimes,  however,  slightly  distended ; stools  were  ordinarily  obtained  only 
by  lavement.  There  was  at  the  same  time  febrile  disturbance,  which,  in  the  course 
of  the  day,  was  not  considerable,  but  which,  every  night,  was  characterised  by  an 
exacerbation  not  preceded  by  any  shivering,  but  which  ended  every  morning  in  a 
profuse  sweat.  Some  of  these  patients  were  subjected  to  an  expectant  treatment, 
and  they  recovered  very  slowly  ; others  were  bled  without  any  relief.  In  one 
patient  the  first  febrile  exacerbation  which  took  place  came  on  in  the  evening  of  the 
day  on  which  leeches  had  been  applied  to  the  epigastrium.  In  no  instance  was 
the  violence  of  the  fever  diminished  after  bleeding.  In  several,  again,  the  tartar 
emetic  was  tried,  and  we  were  singularly  struck  with  the  prompt  change  for  the 
better  which  immediately  followed  the  use  of  this  medicine,  with  some  exceptions, 
which  we  shall  notice  presently.  Once  they  took  the  tartar  emetic,  and  had 
vomited  copiously,  the  nausea  and  vomiting  no  longer  returned,  the  febrile  dis- 
turbance disappeared,  and  a rapid  cure  took  place.  In  three  patients,  however, 


154 


ANDRAL’S  MEDICAL  CLINIC. 


this  did  riot  occur;  in  one  of  them  the  employment  of  the  tartar  emetic  was  not 
followed  by  any  change,  good  or  bad ; in  the  other  two  the  nausea  and  spon- 
taneous vomiting  also  ceased,  but  the  tongue  became  red  and  dry,  the  abdomen 
was  slightly  tympanitic,  the  yellow  tint  of  the  face,  far  from  diminishing,  in- 
creased, and  a certain  air  of  stupor  was  diffused  over  the  countenance.  In 
these  two  cases  leeches  were  applied  to  the  epigastrium,  and  the  patients  ap- 
peared to  derive  benefit  from  them.  It  is  probable  that,  in  the  three  patients 
now  mentioned,  and  particularly  in  the  two  latter,  there  existed  a morbid  state 
different  from  that  which  existed  in  the  others,  to  whom  the  emetic  had  been 
given  with  indisputable  advantage.  Perhaps  these  are  those  cases  so  often 
met  in  the  practice  of  medicine  in  which  lesions  of  a different  kind  are  still  in- 
dicated by  identical  symptoms  ; but  probably,  also,  it  was  a peculiar  disposition 
in  the  individuals,  which,  in  their  case,  rendered  the  employment  of  the  tartar 
emetic  useless  or  injurious.  Be  this  as  it  may,  by  whatever  conjecture  we 
shall  endeavour  to  explain  the  matter,  we  are  warranted  in  inferring,  from  the 
preceding  facts,  that  the  same  treatment  does  not  always  succeed,  though  em- 
ployed in  cases  of  diseases  which  bear  the  closest  possible  resemblance  with 
respect  to  their  symptoms.  But  this  is  certainly  no  reason  for  renouncing 
medical  treatment,  from  which  a skilful  and  experienced  hand  may  often  derive 
such  great  advantage.  In  that  case  we  should  renounce  therapeutics  altogether  ; 
we  should  no  longer  employ  quinine  in  intermittent  fevers,  nor  opium  to  assuage 
pain. 

On  applying  all  that  has  been  just  said  to  the  subject  now  before  us,  we 
shall  establish  as  corollaries  from  the  preceding  facts,  that,  when  nausea  and 
vomiting  exist  with  the  other  symptoms  which  have  been  just  noticed,  we  may 
cause  them  to  disappear,  and  at  the  same  time  improve  the  entire  system,  by 
giving  a vomit ; and  then  the  well-known  adage,  vomitus  vomitu  curatur  — 
which,  as  a general  principle,  is  false  — is  true  in  a certain  number  of  cases, 
and  rests  on  the  observation  of  undeniable  facts. 

Unfortunately,  and  this  must  be  admitted,  there  will  still  remain  a certain 
vagueness  in  the  practical  determination  of  the  cases  in  which  it  is  proper  to 
give  the  emetic,  so  long  as,  not  knowing  the  morbid  modification  which  is 
removed  by  the  emetic,  we  shall  have  no  other  guide  for  its  employment  than 
the  examination  of  the  symptoms.  For  these  symptoms  may,  to  be  sure,  in 
their  infinite  shades,  point  out  the  change  in  the  indications  to  be  fulfilled  ; they 
may  also  appear  similar  to  us,  their  organic  cause,  however,  being  different. 
Here  are  no  doubt  great  and  serious  difficulties ; but  the  first  condition  for 
making  any  advance  is,  thoroughly  to  know  them ; and  we  think  we  have 
rendered  some  service,  by  pointing  out  these  difficulties  such  as  observation 
presented  them  to  us.  We  may  be  tasked,  to  be  sure,  with  hesitation  and  un- 
certainty of  doctrine,  but  for  this  reproach  we  shall  not  care  much,  as  we  think 
it  not  right  to  be  more  positive  in  a book  than  at  the  bed-side  of  the  patient ; 
and  we  sincerely  pity  the  blindness  and  prejudices  of  those  who,  in  practice, 
consider  as  solved  the  questions  we  have  just  started,  whether  they  think  that 
we  may  always  determine  with  certainty  the  cases  wherein  it  is  useful  to  op- 
pose tartar  emetic  to  gastric  symptoms,  or  whether  they  have  taken  it  as  proved 
that  these  symptoms,  uniformly  aggravated  by  emetics,  should  be  combated  in 
all  cases  by  bloodletting.  For  our  part,  all  we  can  positively  say  is,  that 
neither  are  in  the  right. 

It  should  be  remarked,  that  nausea  and  vomiting  are  much  more  frequent  at 
the  commencement  of  the  disease,  and  when  it  is  still  mild.  These  phenomena 
become  more  and  more  infrequent ; they  even  disappear,  if  they  had  existed,  ac- 
cording as  the  fever  becomes  worse,  particularly  according  as  the  adynamic 
symptoms  come  on.  They  appear  to  us  to  be  so  infrequent  in  this  latter  stage 
of  the  disease,  that  if  they  do  occur  then,  there  is  reason  to  apprehend  that  they 
are  the  symptoms  of  peritonitis  occasioned  probably  by  an  intestinal  perforation.. 


DISEASES  OF  THE  ABDOMEN. 


155 


The  person,  whose  knowledge  of  continued  fevers  should  be  confined  to  the 
morbid  changes  so  frequently  found  in  certain  parts  of  the  digestive  tube  in 
these  diseases,  would  no  doubt  be  inclined  to  think  that  such  serious  lesions  of 
the  intestinal  mucous  membrane  must  be  indicated  by  acute  pains,  and  that 
these  pains  should  constitute  one  of  the  most  ordinary  symptoms  of  most  con- 
tinued fevers.  Yet,  if  he  were  to  go  through  the  cases  contained  in  this  work, 
in  order  to  seek  for  this  symptom,  he  would,  on  the  contrary,  see  that  the  ab- 
dominal pain  is  completely  wanting  in  a great  number  of  cases ; that,  at  other 
times,  it  is  only  transitory,  and  in  a manner  fugitive,  and  that  it  is  even  a little 
acute  only  in  some  cases,  which  are  so  rare  that  they  may  be  considered  as 
real  exceptions. 

Pain,  when  it  does  exist,  may  have  its  seat,  first,  over  the  entire  abdomen, 
where  it  is,  as  it  were,  diffused  ; secondly,  in  some  isolated  points,  and  espe- 
cially in  the  epigastrium,  towards  the  ileo-caecal  region,  around  the  umbilicus, 
in  the  course  of  the  colon.  It  is  in  these  different  points  that  we  must  seek  for 
it,  first  asking  the  patient  whether  he  feels  pain  in  any  of  these  points  ; then 
trying  to  cause  it  by  different  degrees  of  pressure. 

Some  patients  complain  of  suffering  over  the  entire  abdomen.  Over  the 
entire  extent  of  this  cavity  they  experience  a dull  sensibility,  which  is  changed 
into  pain  by  pressure.  This  general  sensibility  may  be  occasioned  by  irri- 
tation of  the  primae  viae  ; but  why  does  this  irritation  produce  it  in  one  case, 
and  not  do  so  in  twenty  others  ? Does  the  peritoneum  then  participate  slightly 
in  the  lesion  of  the  mucous  membrane  ? Is  it  a sign  that  the  intestinal  villosi- 
ties  are  more  especially  affected?  To  these  questions  no  satisfactory  answers 
can  be  yet  given. 

There  is  another  case  in  which  the  pain,  also  extending  over  the  entire  abdo- 
men, is  no  longer  seated  in  the  viscera  of  this  cavity,  but  in  the  skin  of  the 
abdominal  parietes,  or  in  the  subjacent  muscles.  This  pain  is  much  more  acute 
than  the  preceding;  very  slight  pressure  on  the  skin  is  all  that  is  necessary  to 
produce  it ; and  then  it  very  often  happens  that  pain  is  produced,  no  matter  what 
point  of  the  cutaneous  surface  may  be  pressed.  This  pain  should  be  referred 
to  a mere  exaltation  of  the  general  sensibility  ; it  ordinarily  coincides  with  other 
nervous  phenomena. 

In  some  cases,  on  touching  or  pressing  the  abdominal  parietes,  we  ascer- 
tained the  existence  of  a pain,  which  was  also  very  extended,  but  which  still  re- 
cognised another  cause  different  from  the  preceding.  It  seemed  owing  to  an 
effusion  of  blood  which  we  discovered  on  opening  the  body  in  the  muscular 
fasciculi  of  the  abdominal  parietes,  and  particularly  in  the  recti  muscles.  In 
such  cases  the  pain  is  occasionally  very  acute  ; the  slightest  pressure  renders  it 
very  intense,  and  it  might  incline  one  to  believe  in  the  existence  of  a peritonitis. 

The  epigastric  pain  is  far  from  being  constant,  and  our  observations  on  this 
subject  are  fully  in  accordance  with  those  of  M.  Louis,  who  has  found  this 
pain  absent  in  nearly  one  half  of  the  persons  whose  bodies  he  has  opened.  This 
pain  has  been  but  seldom  observed  in  the  cases  of  dothinenterite,  published  by 
M.  Trousseau,  as  also  by  M.  Gendrin.  There  is  scarcely  any  mention  of  it 
in  the  work  of  MM.  Petit  and  Serres.  M.  Bouillaud  seems  to  have  observed 
it  most  frequently. 

When  this  pain  exists,  sometimes  pressure  alone  occasions  it ; sometimes  it 
is  spontaneous.  Patients  complain  of  a constriction,  a weight,  or  else  a more 
or  less  intense  heat  in  the  epigastrium.  The  use  of  drinks  rarely  increases  it;  it 
may  occupy  the  entire  epigastrium,  or  be  limited  to  one  point  of  this  region  ; 
and,  in  this  latter  case,  it  is  principally  on  the  level  of  the  ensiform  cartilage, 
in  the  point  of  the  stomach  corresponding  to  the  cardia,  that  it  is  felt.  In  very 
few  patients  we  have  seen  the  pain  exist  more  particularly  towards  the  great 


156 


ANDRAL’S  MEDICAL  CLINIC. 


cul-de-sac;  in  that  point,  however,  where,  after  death,  the  mucous  membrane 
was  most  frequently  found  changed.  Some  patients  refer  the  painful  sensation 
they  feel  to  a point  higher  up  than  the  epigastrium  ; for  instance,  to  the  lower 
part  of  the  sternum,  to  the  extent  of  three  or  four  fingers’  breadth  above  the 
ensiform  cartilage  ; others  complain  of  something  like  a bar  extended  trans- 
versely from  one  of  the  hypochondria  to  the  other,  passing  over  the  epigastrium. 

In  all  these  varieties  the  epigastric  pain  is  generally  obtuse  ; sometimes,  how- 
ever, it  acquires  such  intensity,  as  to  become  a predominant  symptom,  and  to 
call  for  special  treatment. 

Whatever  be  its  severity.,  the  epigastric  pain  varies  with  respect  to  its  duration 
and  the  time  of  its  appearance.  It  may  commence  with  the  disease,  and  con- 
tinue during  its  entire  course.  After  having  existed  from  the  commencement, 
it  may  promptly  cease,  whether  the  other  symptoms  are  diminished  or  not.  It 
may  also  appear  at  a period  of  the  disease  more  or  less  remote  from  its  com- 
mencement. We  have  seen  some  persons  in  whom,  three  or  four  weeks  after 
the  invasion  of  the  disease,  there  had  existed  an  epigastric  pain,  without  any 
other  appreciable  derangement  of  health. 

The  epigastric  pain  generally  indicates  a state  of  irritation  of  the  stomach, 
but  it  is  not  connected  with  any  special  lesion  of  this  organ.  It  may  present  all 
the  possible  varieties  of  hyperemia,  softening,  and  ulceration,  without  having 
ever  been  the  seat  of  the  least  pain.  On  the  other  hand,  the  stomach  has  been 
found  healthy  in  persons  whose  epigastrium  had  been  the  seat  of  pain.  M.  Louis 
mentions  five  persons  whose  stomach  presented  nothing  remarkable,  and  who 
had  had  pains  in  the  epigastrium.  But  he  does  not  tell  us  whether  these  pains 
still  existed  at  the  time  of  death.  The  result  of  the  observations  of  this  author 
— a result  which  also  corresponds  with  our  own  — is,  that  when  the  pain  in  the 
epigastrium  co-exists  with  the  vomiting  of  bile,  there  is  every  reason  for  think- 
ing that  these  two  symptoms  combined  are  the  result  of  a real  inflammatory  state 
of  the  stomach. 

We  should  not  forget  that,  in  a very  considerable  number  of  persons  attacked 
with  continued  fever,  there  is  such  a distension  of  the  colon,  that  when  the  epi- 
gastrium is  pressed,  the  pressure  is  on  the  colon  and  not  on  the  stomach. 
Neither  should  we  forget  that,  in  many  persons  in  very  excellent  health,  pres- 
sure not  at  all  violent,  made  on  the  epigastrium,  occasions  a painful  sensation. 

We  have  above  pointed  out  the  points  of  the  abdomen,  besides  the  epigastrium, 
which  become  more  particularly  painful.  At  these  different  points  the  pain  may 
be  spontaneous,  or  may  be  produced  only  by  pressure.  Oftentimes  also  it  is  not 
felt  except  when  the  patient  has  occasion  to  go  to  stool;  it  is  then  simple  colic. 
But  this  latter  symptom  does  not  even  necessarily  accompany  the  purging  which 
comes  on  at  different  stages  of  fever.  There  are  some  patients  who  have  very 
copious  and  almost  continual  stools,  without  any  painful  sensation.  There  are 
others  who  feel  nothing  but  a little  heat  towards  the  fundament. 

In  these  cases,  however,  where  the  abdomen,  when  pressed  in  every  point, 
is  not  found  to  be  painful,  the  mucous  membrane  is  most  usually  seriously  altered. 
Confirming,  by  our  researches,  the  splendid  observations  of  M.  Broussais  with 
respect  to  the  indolent  character  of  several  intestinal  inflammations,  we  stated 
in  the  first  edition  of  this  work,  that  a person  would  be  liable  constantly  to 
overlook  the  most  severe  cases  of  enteritis,  if  he  would  not  admit  its  existence 
except  when  pain  was  present.  Since  the  publication  of  our  researches  on  this 
subject,  numerous  works,  published  by  men  of  the  most  different  schools,  have 
demonstrated  that  the  intestines  may  be  very  seriously  affected,  without  any  pain 
being  felt.  We  have  also  seen  this  pain  absent:  1st,  in  cases  of  simple  ery- 
thema of  the  mucous  membrane  ; 2d,  in  those  cases  where  numerous  exanthema- 
tous patches  covered  the  inner  surface  of  the  small  intestine  ; 3d,  in  other  cases 
where,  instead  of  patches,  there  was  observed  in  the  small  or  large  intestine  only, 


DISEASES  OF  THE  ABDOMEN. 


157 


a greater  or  less  number  of  Isolated  papulae  ( boutons ) ; 4th,  in  cases  also  where 
ulcerations  had  formed  either  in  the  ileum,  or  on  either  surface  of  the  ileo-caecal 
valve,  or  in  the  caecum,  colon,  or  even  in  the  rectum.  We  have  met  subjects 
in  whom  the  ulcerations  had  nothing  but  the  peritoneal  coat  for  their  bottom, 
and  yet  these  persons  had  never  felt  any  pain  ; and  observe,  that  we  here  speak 
only  of  cases  where  the  patients  still  enjoyed  the  free  exercise  of  their  intellect 
at  the  time  we  wished  to  ascertain  the  existence  of  pain  in  the  several  points  of 
the  abdomen. 

There  are  cases  where,  after  all  the  symptoms  have  disappeared,  there  still 
remains  a diarrhcea  which  interferes  with  convalescence,  and  which  it  is  import- 
ant  to  combat.  But  what  means  should  be  employed,  and  should  the  choice  ot 
these  means  be  regulated  by  the  presence  or  absence  of  abdominal  pain?  We  do 
not  think  so.  We  have  very  frequently  met  with  these  indolent  diarrhoeas,  the 
cause  of  which  anatomy  proved  to  reside  in  intestinal  ulcerations. 

One  of  the  most  constant  phenomena  of  continued  fevers  is  the  change  observed 
in  the  alvine  evacuations,  which  sometimes  become  more  scanty,  and  sometimes 
more  copious  than  ordinary. 

Constipation,  which  is  more  unfrequent  than  diarrhoea,  sometimes  continues 
during  the  entire  course  of  the  disease,  whether  it  terminates  favourably  or  fatally. 
Thus,  the  person  who  forms  the  subject  of  the  first  case,  and  who  did  not  die 
till  the  thirty-first  day,  had  never  any  purging  ; no  ulcerations  were  found  in 
the  intestines,  but  merely  a tumefied  state  of  the  follicles  of  the  small  intestines, 
with  redness  of  the  caecum.  In  other  cases,  the  constipation  exists  only  at  the 
commencement  of  the  disease  ; it  is  then  succeeded  by  a diarrhoea,  more  or  less 
profuse. 

The  diarrhcea  may  commence  at  different  periods  of  the  disease.  With 
respect  to  the  time  of  its  appearance,  the  following  cases  should  be  distin- 
guished : — 

First  Case.  Appearance  of  diarrhoea,  for  a longer  or  shorter  time,  before  all 
the  other  symptoms.  Thus,  several  of  our  patients  stated  to  us,  that  for  several 
days,  or  even  several  weeks,  before  they  were  confined  to  bed,  they  had  been 
seized  with  a purging,  which  in  some  was  continual,  and  in  others  appeared 
only  at  intervals.  According  as  this  purging  was  prolonged,  they  felt  their  ap- 
petite diminish,  and  their  strength  sink;  at  last  they  were  attacked  with  fever, 
and  then  they  entered  the  hospital. 

Second  Case.  Simultaneous  invasions  of  the  diarrhoea,  and  of  the  other  symp- 
toms. This  was  the  case  with  a certain  number  of  our  patients,  who  had  not 
perceived  the  least  alteration  in  their  health  ; when  on  a sudden,  after  causes 
more  or  less  appreciable,  they  were  attacked  at  the  same  time  with  purging  and 
fever.  This  purging  was  frequently  very  severe  from  its  commencement.  In 
some  it  did  not  commence  till  after  a violent  shivering. 

Third  Case.  Appearance  of  diarrhoea  several  days  after  the  invasion  of  the 
fever.  It  then  very  rarely  succeeds  to  natural  stools,  more  frequently  to  a more 
or  less  obstinate  constipation  ; it  sometimes  comes  on  without  any  known  cause, 
and  sometimes  follows  the  employment  of  something  stimulating.  We  have 
more  than  once  seen  it  come  on,  so  as  never  again  to  be  checked,  after  the  pa- 
tients had  taken  calomel,  which  had  been  given  to  overcome  their  constipation. 
In  some  it  set  in  gradually,  and  at  first  its  existence  was  scarcely  perceived  ; at 
first,  there  were  in  the  twenty-four  hours  only  one  or  two  stools  of  bad  consist- 
ence. In  others,  it  was  very  severe  from  the  commencement.  Patients  who  had 
been  for  several  days  without  going  to  stool,  have  had  suddenly,  in  the  course 
of  a few  hours,  a very  great  number  of  alvine  evacuations.  The  sudden  setting 
in  of  so  severe  a diarrhcea  generally  coincides  with  an  aggravation  of  the  other 
symptoms.  It  is  frequently  at  this  time  that  we  see  the  form  of  what  is  called 
inflammatory,  or  bilious  fever,  pass  rapidly  to  the  adynamic  or  ataxic  form.  One 
14 


158 


AN  DUAL’S  MEDICAL  CLINIC. 


of  the  most  remarkable  cases  of  this  kind  which  we  have  had  an  opportunity  of 
seeing  is  the  following:  — 

A young  man,  just  after  being  appointed  an  officer  of  health,  was  preparing 
to  leave  Paris,  when  he  was  seized  with  violent  headach  and  fever.  For  ten 
days  he  presented  the  symptoms  of  inflammatory  fever  : the  headach  was 
very  severe,  and  the  bowels  were  constipated.  He  was  repeatedly  bled,  but 
this  did  not  diminish  either  the  headach  or  the  other  symptoms : there  was  as 
yet  nothing  in  his  case  decidedly  alarming  ; the  intellect  had  remained  perfectly 
clear,  when  a few  hours  after  the  application  of  leeches  to  the  anus,  the  con- 
stipation, which  had  continued  till  that  time,  was  suddenly  succeeded  by  very 
profuse  diarrhoea.  From  this  moment,  sudden  prostration  set  in,  rapid  sinking 
of  the  features,  repeated  epistaxis,  dry  and  fuliginous  state  of  the  tongue,  tym- 
panitic state  of  the  abdomen,  extreme  frequency  of  the  pulse,  subsultus  tendi- 
num,  delirium,  and  death  in  less  than  fifty  hours  after  the  appearance  of  the 
diarrhoea. 

Fourth  Case.  Appearance  or  continuance  of  the  diarrhoea  during  conva- 
lescence. It  is  not  a common  circumstance  for  diarrhoea  to  occur  for  the  first 
time  when  convalescence  is  established  ; but  it  is  more  common  to  see  it  con- 
tinue, and  even  become  more  profuse,  at  the  very  period  of  convalescence. 
The  diarrhoea  is  then  often  very  inconsiderable,  and  does  not  attract  attention ; 
still  the  patient’s  strength  does  not  return,  or  it  again  diminishes  after  having 
appeared  to  be  re-established  ; the  skin  continues  dry  ; after  some  time  the 
pulse  becomes  a little  frequent;  a slight  febrile  disturbance  appears,  either  con- 
stant, or  only  at  intervals  ; the  patient  remains  pale,  as  it  were  anemic,  and  it 
is  quite  evident  that  he  is  every  day  sinking.  Yet  the  local  symptoms,  which 
can  account  for  such  a state,  are  often  scarcely  marked  ; the  patients  ask  for 
food  ; their  appetite  and  digestion  appear  good  ; the  abdomen  is  soft,  free  from 
pain  in  every  part,  and  there  are  at  most  but  two  or  three  stools  in  the  twenty- 
four  hours  ; sometimes  even  this  number  of  stools  occurs  only  every  three  or 
four  days,  and  every  twenty-four  hours  there  is  but  one  liquid  stool.  Not- 
withstanding this  apparently  mild  nature  of  the  local  symptoms,  the  marasmus 
proceeds,  and,  after  a longer  or  shorter  time,  the  patients  die.  When  their 
bodies  are  opened,  there  are  found  in  the  intestine,  in  the  place  of  the  aggre- 
gated follicles,  ulcerations  more  or  less  extensive  both  in  breadth  and  depth. 

This  is  what  takes  place  in  certain  cases  ; in  others  the  local  symptoms  are 
more  marked  ; the  appetite  is  nearly  gone  ; or  else,  if  the  patients  still  have  a 
desire  for  food,  it  is  badly  digested,  or  it  goes  to  increase  the  purging.  The 
abdomen  is  a little  sensible  on  pressure  ; the  patients  feel  it  painful  even  with- 
out pressure  ; the  stools  are  more  profuse  than  in  the  preceding  case ; they  are 
more  watery,  and  are  sometimes  tinged  with  blood.  On  opening  the  bodies 
of  such  patients  no  other  lesion  is  found  but  that  observed  in  the  patients  men- 
tioned in  the  preceding  paragraph  ; and  here  again  is  a case  where,  in  conse- 
quence of  certain  dispositions  of  the  system  which  escape  us,  identical  lesions 
give  rise  to  different  symptoms.  But  a circumstance,  which  we  shall  not  neglect 
to  notice,  is,  that  in  these  two  cases,  where  the  local  symptoms  referable  to 
the  intestinal  lesion  are  so  little  alike,  the  treatment  should  continue  the  same. 
In  neither  of  these  two  cases  have  we  seen  tonic  or  astringent  substances  suc- 
ceed. The  identity  of  the  lesions  in  these  two  cases  sufficiently  accounts  for 
the  identity  of  therapeutic  results,  which,  by  the  mere  consideration  of  the 
symptoms,  we  never  could  comprehend. 

It  has  been  said  that  diarrhoea  indicated  irritation  of  the  large  intestine  ; it 
has  been  given  as  the  sign  of  colitis  ; and  it  has  been  affirmed  that,  as  long  as 
irritation  was  confined  to  the  small  intestine,  constipation  existed.  Our  ob- 
servations by  no  means  accord  with  these  ideas.  We  have  found,  in  several 
instances,  the  large  intestine  perfectly  healthy  through  its  entire  extent,  though, 


DISEASES  OF  THE  ABDOMEN. 


159 


during  life,  and  up  to  the  moment  of  death,  profuse  diarrhoea  had  existed.  It 
appeared  to  us  sufficient  to  produce  purging  that  the  termination  of  the  small 
intestine  should  be  altered  in  any  manner  whatever.  Here,  again,  the  re- 
searches of  M.  Louis  are  confirmatory  of  ours. 

Can  the  nature  of  the  stools  afford  any  information  with  respect  to  the  nature 
or  severity  of  the  alteration  which  the  intestine  has  undergone?  We  do  not 
think  it.  Whether  there  be  simple  erythema  of  the  mucous  membrane,  tume- 
faction of  the  follicles,  or  ulceration,  we  see  the  stools  sometimes  serous,  and 
resembling  water,  tinged  yellow  or  green  ; sometimes  appearing  to  consist  of 
nearly  pure  bile  ; sometimes  mucus  ; at  other  times  resembling  pease-soup  of  a 
blackish  brown  colour,  or  of  a grey  ashy  colour ; at  other  times  mixed  with 
blood.  There  are  cases  where  the  latter  fluid  itself  forms  the  entire  matter" of 
the  stools  ; the  quantity  of  blood  voided  by  the  anus  is  then  sometimes  very 
considerable ; in  some  patients  there  is  observed  only  one  evacuation  of  this 
kind  ; in  others  it  is  several  times  renewed  ; the  patients  void  at  intervals,  more 
or  less  remote,  a stream  of  blood,  which,  when  received  into  a vessel,  might 
be  taken  for  blood  drawn  from  a vein.  Should  these  evacuations  be  renewed 
or  continued,  they  are  followed  by  perceptible  sinking  of  the  subject,  who  soon 
dies  in  an  adynamic  state.  On  opening  the  body,  blood  is  found  accumulated 
in  the  intestine,  and  no  other  lesion.  Whatever  be  the  severity  of  such  a he- 
morrhage, it  does  not  invariably  prevent  the  recovery  of  the  patient.  In  all 
the  cases  which  we  saw  the  individuals  died  ; but  M.  Louis  has  seen  three 
cases  where,  notwithstanding  this  hemorrhage,  recovery  took  place.*  In  two 
of  the  cases  which  he  records  the  blood  was  voided  in  the  form  of  clots  : some 
blood  had  been  passed  during  three,  four,  and  six  days  successively.  In  these 
three  patients  there  was  at  the  same  time  epistaxis,  which  in  one  of  them  was 
very  profuse.  Again,  the  intestinal  mucous  membrane  may  exhale  blood  in 
great  quantity  without  this  hemorrhage  being  indicated  by  the  nature  of  the 
stools.  Thus,  in  one  of  our  own  cases,  it  was  not  discovered  till  the  post- 
mortem examination  was  made  ; the  blood  exhaled  in  the  small  intestine,  which 
it  filled,  had  not  passed  the  ileo-ccecal  valve. 

If  we  consider  diarrhoea  in  reference  to  the  modifications  which  it  may  under- 
go from  the  therapeutic  means,  the  different  effects  of  which  we  have  traced  in 
our  particular  cases  ; first,  we  shall  see  that,  in  a great  number  of  cases,  the 
alvine  evacuations  were  diminished  or  arrested  after  the  application  of  leeches 
to  the  anus  ; whilst,  in  other  cases  equally  numerous,  these  applications  have 
had  no  influence  whatever  on  the  diarrhoea.  With  respect  to  the  influence  of 
emetics  on  diarrhoea,  we  may  divide  the  individuals  subjected  to  this  treatment 
into  four  classes.  In  some  the  diarrhoea  was  increased,  or  showed  itself  for  the 
first  time  after  the  administration  of  the  emetic ; in  others  the  diarrhoea  was 
momentarily  increased,  and  then  ceased  in  twenty-four  hours  ; in  other  cases  it 
ceased  suddenly  after  the  vomit ; whilst  in  others  it  did  not  appear  to  be  at  all 

* Since  this  was  written,  we  too  have  met  cases  in  which  profuse  intestinal  hemorrhage, 
coming  on  during  the  progress  of  bad  fevers,  have  not  prevented  the  disease  from  terminating 
favourably.  These  hemorrhages  take  place  in  general  only  at  a very  advanced  stage  of  the 
disease ; yet  we  have  very  recently  seen  a case  in  which  three  pounds  of  blood  at  least  were 
passed  by  the  anus  very  near  the  commencement  of  the  affection.  The  individual  who  forms 
the  subject  of  this  case  had  been  ill  but  three  days,  and  from  that  time  he  had  fever  without 
well  marked  symptoms,  when,  on  a sudden,  after  having  felt  some  colicky  pains,  he  voided  the 
above  mentioned  quantity  of  blood  all  at  once  on  going  to  stool.  After  this  discharge  the 
patient  was  in  a state  of  prolonged  syncope.  We  gave  him  a small  starch  enema,  with  the 
addition  of  two  drachms  of  extract  of  rhatany  and  a drachm  of  diascordium.  Sinapisms  were 
applied  to  the  extremities,  and  a decoction  of  rice,  with  ice,  was  given  him.  The  hemorrhage 
did  not  return  ; and  the  patient  afterwards  passed  through  the  ordinary  stages  of  typhoid  fever, 
which  terminated  favourably. 


ANDRAL’S  MEDICAL  CLINIC. 


160 

influenced  by  emetics.  With  respect  to  quinquina,  and  other  tonics  given  in 
the  form  of  lavement,  we  have  never  seen  them  stop  diarrhoea.  When  directly 
introduced  into  the  stomach,  they  have  been  followed  several  times  by  a cessa- 
tion of  the  purging.  We  have  not  ascertained  that  any  favourable  effect  was 
produced  in  any  case  of  diarrhoea  by  topical  irritants,  whether  applied  to 
the  upper  extremities  or  to  the  abdomen.  The  diarrhoea  of  convalescents  has 
been  frequently  diminished  by  the  employment  of  the  half  or  fourth  part  of  the 
ordinary  starch  enema,  to  which  there  is  added  from  five  to  twenty  drops  of 
laudanum. 

In  the  preceding  remarks  we  have  only  considered  purging  as  an  accident  which 
increases  the  chances  of  the  disease  becoming  severe  ; yet  some  of  our  cases 
afford  instances  where,  at  the  same  time  that  the  fever  ceased,  and  the  other 
symptoms  improved,  the  diarrhoea,  on  the  contrary,  was  visibly  increased.  In 
other  cases  we  have  seen  it  appear  for  the  first  time  just  at  the  very  moment  when 
also  for  the  first  time  there  appeared  a tendency  in  the  disease  to  a favourable 
termination.  Sometimes  again  it  comes  on  during  convalescence,  without  ap- 
pearing in  any  manner  to  interfere  with  its  progress.  It  is  facts  of  this  kind 
no  doubt  which  made  the  ancients  think  that  in  some  continued  fevers  diarrhoea 
is  critical , whilst  in  others  perspiration  constitutes  the  crisis.  For  our  part  we 
shall  say  that  the  cases  of  continued  fever  in  which  we  saw  the  establishment 
of  diarrhoea  followed  by  any  advantage  are  so  few,  that  we  cannot  conclude 
anything  from  them  with  respect  to  the  critical  nature  of  this  phenomenon. 
Here,  however,  we  thought  it  right  to  cite  these  cases,  because  facts  cannot  be 
useful  except  by  considering  them  in  every  point  of  view,  and  it  is  not  devoid 
of  utility  occasionally  to  subject  to  new  inquiries  those  points  of  doctrine  which 
under  the  influence  of  theories  different  from  ours  formerly  occupied  so  exten- 
sive a place  both  in  science  and  practice.  Was  it  observation,  or  mere  theory, 
that  induced  Huxliam  to  lay  it  down,  that  delirium  and  disposition  to  coma  dis- 
appear as  soon  as  purging  sets  in?  Was  it  by  facts  that  Pringle  was  led  to 
consider  diarrhoea  as  ordinarily  serving  for  a crisis  in  the  remittent  fevers  of 
which  he  has  given  us  so  valuable  a description  ? He  recommended  that  the 
purging  in  these  diseases  should  not  be  checked  too  soon.  Grant  also  considered 
diarrhoea  to  be  the  natural  crisis  of  putrid  fever.  In  our  opinion  all  these  ideas 
rest  on  facts  which  are  real  but  incorrectly  interpreted.  The  authors  just  now 
cited  had  seen,  as  we  did,  that  at  a certain  period  of  fever  diarrhoea  ordinarily 
comes  on  ; this  is  the  fact,  which  observation  must  have  supplied  to  them  as 
well  as  to  us.  But  with  us,  this  diarrhoea  is  the  natural  result  of  the  intestinal 
lesion,  the  existence  of  which  has  been  ascertained  in  those  diseases  by  ana- 
tomical research.  With  those  whose  theory  taught  them  that  every  disease 
must  terminate  by  the  evacuation  of  the  morbific  matter,  this  diarrhoea  which 
came  on  towards  the  termination  of  the  fever  must  arise  from  nature’s  effort  to 
accomplish  this  evacuation.  In  their  time,  as  in  our  own,  death  must  very 
often  have  occurred  during  the  course  of  the  diarrhoea ; but  then  they  admitted  that 
the  crisis  had  not  been  sufficient.  In  a word,  the  most  powerful  argument 
which  they  thought  could  be  adduced  in  favour  of  their  theory  was,  that  in 
attempting  to  check,  and  in  actually  checking  the  purging,  much  mischief  was 
done.  I admit  this,  for  in  order  to  accomplish  this  they  employed  irritating 
substances  which  suppressed  the  stools  only  by  very  much  aggravating  the 
gastro-intestinal  lesion.  It  was  not  then  the  suppression  of  the  crisis,  as  they 
called  it,  that  was  injurious,  it  was  the  increase  of  irritation  which  they  pro- 
duced in  the  primae  viae.  This  is  no  doubt  a very  remarkable  instance  of  the 
difference  of  the  theoretical  conclusions  to  which  persons  may  arrive  by  setting 
out  from  one  and  the  same  real  and  well-observed  fact. 

We  have  already  spoken  of  meteorism,  of  its  most  frequent  seat,  and  of  its 


DISEASES  OF  THE  ABDOMEN. 


161 


connexion  with  the  lesion  of  the  intestinal  mucous  membrane.  We  have  seen 
that  residing  principally  in  the  colon  ; it  could  not  be  accounted  for  by  any  of 
the  alterations  discovered  in  this  intestine*  b y post-mortem  examination. 

This  meteorism  does  not  usually  come  on  till  rather  an  advanced  stage  of 
the  disease  ; it  precedes  or  follows  the  occurrence  of  purging ; it  is  sometimes 
only  temporary,  whilst  sometimes,  when  once  produced,  it  continues  ; it  pre- 
sents several  degrees  from  that  where  it  can  be  detected  only  by  percussion, 
to  that  degree  in  which  the  colon  is  so  distended  that  its  form  is  accurately 
delineated  through  the  abdominal  parietes  ; when  it  has  attained  this  degree,  the 
large  intestine  occupies  nearly  the  entire  abdomen,  and  pressing  against  the 
diaphragm  it  produces  most  alarming  dyspnoea. 

Meteorism,  to  any  extent,  is  a symptom  which  very  much  increases  the 
unfavourable  character  of  the  prognosis.  Whatever  be  its  proximate  cause,  it 
always  indicates  a state  of  the  system  in  which  there  is  a great  sinking  of  the 
powers  of  life,  and  progressive  tendency  to  prostration,  which  is  only  aggravated 
by  bloodletting. 

Still,  though  this  is  a very  alarming  symptom,  we  must  not  forget  that  several 
of  our  patients  who  had  it  to  a very  considerable  extent,  recovered  notwithstand- 
ing. We  have  not  discovered  any  therapeutic  agent  which  could  act  directly 
on  it. 


CIRCULATORY  APPARATUS. 


SECTION  I. 

LESIONS  FOUND  AFTER  DEATH  IN  THE  CIRCULATORY  APPARATUS, 

We  shall  in  the  next  place  trace  those  lesions  in  the  heart,  arteries,  and  veins. 

The  heart,  whose  action  is  uniformly  disturbed  in  persons  affected  with  con- 
tinued fevers,  very  rarely  presented  on  the  dead  body  any  appreciable  alteration. 
In  the  great  majority  of  the  cases  already  reported  by  us,  the  heart  was  found 
to  be  in  every  respect  in  its  normal  state.  In  fact,  out  of  ninety-eightf  cases 
of  continued  fever,  which  terminated  fatally,  only  thirteen  presented  any  trace 
of  morbid  change  in  the  heart,  and  in  some  of  those  the  change  was  very  slight ; 
thus  in  those  thirteen  we  twice  found  nothing  else  than  unusual  paleness  of  the 
tissue  of  the  heart.  Another  time  this  pale  colour  coincided  with  a flaccid  state 
of  the  heart’s  parietes.  On  two  occasions  the  muscular  substance  of  the  heart 
appeared  to  us  to  have  lost  its  ordinary  consistence,  and  six  times  it  presented 
an  unusual  red  tint,  either  in  its  substance,  or  on  its  inner  surface. 

* The  exhalation  of  a great  quantity  of  gas  into  the  intestine  is  so  independent  of  an  inflam- 
matory state  of  this  part,  that,  on  the  one  hand,  we  see  tympanitis  developed  in  cases  where 
there  certainly  exists  nothing  resembling  an  enteritis,  as  in  certain  neuroses,  and,  on  the  other 
hand,  it  is  not  observed  in  phthisical  subjects,  whose  intestines  present  all  possible  varieties 
of  inflammation.  We  do  not  remember  to  have  seen  well-marked  tympanitis,  except  in  one 
patient,  of  this  latter  description.  This  case  appeared  so  much  the  more  striking,  as  after 
having  continued  for  a certain  time,  the  gaseous  secretion  ceased  all  at  once.  This  individual 
had  purging,  gases  had  been  passed  in  great  quantity  by  the  anus,  and  yet  the  abdomen,  which 
was  very  inflated,  did  not  diminish  in  size.  This  tympanitis  continued  for  nearly  three  weeks. 
At  the  end  of  this  time  the  abdomen  returned  spontaneously  in  the  course  of  forty-eight  hours 
to  its  ordinary  size,  without  the  patient  having  passed  by  the  anus  more  gases  than  on  the 
preceding  days.  This  patient  died  a little  after.  Cavities  were  found  in  his  lungs,  ulcerations 
and  tubercles  in  the  intestines. 

t Only  the  more, interesting  of  those  ninety-eight  cases  have  been  here  given. — Tn. 

14* 


162 


ANDRAL’S  MEDICAL  CLINIC. 


If  we  compare,  on  the  point  of  view  now  before  us,  our  observations  with 
those  of  MM.  Bouillaud  and  Louis,  we  shall  find  a discordance  between  their 
results  and  ours.  For,  whilst  the  cases  in  which  we  have  met  the  heart  free 
from  all  appreciable  lesion,  are  much  more  numerous  than  those  in  which  the 
heart  no  longer  appeared  in  its  normal  state,  the  two  observers  just  named  have 
arrived  at  the  very  opposite  conclusion.  Thus,  in  forty-nine  autopsies,  M. 
Bouillaud  found  the  heart  in  its  normal  state  only  twelve  times.  In  fifty-four 
autopsies,  M.  Louis  found  the  heart  in  its  natural  state  only  twenty-seven  times. 
It  may  be  observed  that  the  morbid  changes  found  by  them  in  the  heart  are  of 
the  same  nature  as  those  mentioned  in  our  own  cases.  Thus  the  heart  was 
found  paler  than  natural  three  times  by  M.  Bouillaud,  and  five  times  by  M. 
Louis.  It  was  found  redder  in  its  fleshy  tissue,  or  on  its  inner  surface,  eleven 
times  by  M.  Bouillaud,  and  three  times  by  M.  Louis.  Again,  the  former  ob- 
server found  it  diminished  in  consistence  seven  times,  and  the  latter  twenty- 
four  times  ; but  in  these  31  cases,  it  was  seldom  that  any  considerable  softening 
was  observed  ; most  frequently  it  was  but  a state  of  flaccidity,  or  else  a-less 
resistance  than  usual  to  the  efforts  made  to  tear  the  substance  of  the  heart. 

We  shall  see  presently  how  far  we  shall  be  able  to  explain  the  difference  of 
the  results  now  noticed.  We  must  say,  however,  beforehand,  that  we  have  been 
able  to  pay  less  attention  than  M.  Louis  to  the  changes  in  the  heart’s  consistence, 
and  that  they  may  have  escaped  us  several  times,  but  the  same  thing  cannot  be 
said  of  the  redness  both  of  that  of  the  heart  and  of  the  vessels,  and  we  are  quite 
sure,  that  every  time  we  did  not  note  this  phenomenon,  it  did  not  exist. 

To  sum  up,  out  of  two  hundred  and  one  'post-mortem  examinations  of  persons 
who  died  of  continued  fevers,  we  found  one  hundred  and  twenty-four  in  whom 
the  heart  was  in  its  normal , and  seventy-five  in  whom  it  was  in  the  anormal 
state. 

Let  us  now  follow  up  our  examination  of  the  circulating  apparatus  in  persons 
who  died  of  continued  fevers,  by  studying  the  state  of  the  vessels  in  them. 

In  the  sixty-five  cases  examined  by  us,  we  found  the  aorta  coloured  red  on  its 
inner  surface  only  six  times,  and  the  veins  in  nearly  the  same  proportion. 

Out  of  the  thirty-three  other  cases  which  also  fell  under  our  observation,  there 
were  seven  in  which  we  detected  this  same  redness. 

Our  cases  presented  to  us  no  other  alteration  in  the  vessels  but  this  redness, 
with  the  exception  of  one  in  which  we  found  some  of  the  veins  filled  with  pus. 

Out  of  the  forty-nine  post-mortem  examinations  of  patients  who  died  of  con- 
tinued fevers,  reported  in  the  work  of  M.  Bouillaud,  there  were  but  eight  in 
which  this  author  detected  any  redness  on  the  inner  surface  of  the  vessels. 

In  the  four  cases  cited  by  M.  Bouillaud,  the  individuals  in  question  presented, 
after  external  lesions,  or  after  accouchement,  all  the  symptoms  of  adynamic  fever, 
in  whom,  after  death,  several  veins  were  found  ulcerated  on  their  inner  surface, 
covered  with  false  membranes,  or  full  of  pus. 

Out  of  fifty-four  cases  observed  by  M.  Louis,  there  were  twenty  in  which  the 
aorta  was  red. 

Thus  out  of  two  hundred  and  one  individuals  who  died  of  continued  fevers,  we 
find  one  hundred  and  fifty-five  in  whom  the  vessels  were  in  a normal  state,  and 
forty-six  in  whom  there  was  an  anormal  state  of  these  same  vessels. 

But  does  this  anormal  state  exist  during  life  ? Has  it  performed  any  part  in 
the  production  of  the  symptoms  ? Is  it  produced  only  after  death  ? Has  it  been 
taken  for  a disease,  when  it  was  but  a cadaveric  lesion  ? 

Before  discussing  those  important  questions,  we  should  remark,  that  both  in 
the  individuals  who  fell  under  our  own  observation,  and  in  those  whose  cases 
have  been  reported  by  MM.  Louis  and  Bouillaud,  the  symptoms  differed  in  no 
respect  from  the  symptoms  observed  in  persons  whose  heart  and  vessels  were 
found  in  the  normal  state.  This  identity  of  symptoms  has  also  been  observed 


DISEASES  OF  THE  ABDOMEN. 


1G3 


by  M.  Louis.  M.  Bouillaud  has  thought  that  the  symptoms  of  what  is  called 
inflammatory  fever  should  be  referred  to  an  angeio-carditis,  which  was  proved 
only  by  the  red  colouring  of  the  internal  surface  of  the  heart  and  vessels.  But 
on  the  one  hand  we  have  cited  some  instances  wherein  these  symptoms  were 
similar  to  those  given  by  M.  Bouillaud,  as  appertaining  to  inflammatory  fever, 
and  in  which  there  was  not  any  redness,  either  in  the  heart  or  in  the  vessels. 
On  the  other  hand,  M.  Bouillaud  himself  states,  that  he  has  found  this  same 
redness  in  the  fever  called  putrid  or  adynamic.  He  has  also  met  it  in  a certain 
number  of  persons  who  died  in  the  last  stage  of  pulmonary  phthisis,  and  who 
were  wasted  by  hectic  fever.  This  redness  did  not  then  belong  exclusively  to 
inflammatory  fever,  according  to  M.  Bouillaud’s  own  researches. 

It  was  met  in  every  fever ; it  might  be  its  cause,  or  at  least,  its  anatomical 
character.  ♦ But  who  does  not  know  that  redness  of  the  heart,  as  well  as  of  the 
vessels,  is  wanting  in  a very  great  number  of  individuals  who  have  died  of  some 
form  or  other  of  fever  ? 

But  further;  this  redness  is  not  confined  merely  to  cases  of  what  are  called 
essential  fevers.  We  have  frequently  met  it  in  persons  who  have  died  of  dis- 
eases totally  different.  On  referring  to  our  notes,  we  find  the  following  to  be 
the  results  of  our  observations  on  this  matter:  — 

1.  State  of  the  heart  and  vessels  in  persons  who  died  of  some  other  disease, 
whilst  they  had  fever. 

Times. 

In  seven  cases  of  acute  peritonitis,  there  was  redness  of  the  heart 


and  aorta  ......  5 

In  five  cases  of  puerperal  peritonitis  . . .3 

In  ten  cases  of  acute  pneumonia  . . . . 1 

In  sixty-one  cases  of  pulmonary  phthisis  with  hectic  fever  . 9 


Total.  In  eighty-three  cases  of  febrile  disease  18 


2.  State  of  the  heart  and  vessels  in  persons  who  died  without  fever. 

Times. 

In  thirty-one  cases  of  organic  lesions  of  the  heart,  there  was 


redness  of  the  heart  and  aorta  . . . .11 

In  nine  cases  of  apoplexy  . . . . .2 

In  five  cases  of  chronic  peritonitis  . . . . 1 

In  thirteen  cases  of  chronic  gastritis  . . .3 

In  two  cases  of  cancerous  affections  of  the  liver'  . . 1 

In  four  cases  of  ascites  with  atrophy  of  the  liver  . . 1 

In  six  cases  of  encysted  dropsy  of  the  ovary  . . 2 

In  five  cases  of  tetanus  . . . . .2 


Total.  In  seventy-five  cases  of  disease  not  febrile  23 

On  comparing  the  result  of  No.  1 with  that  of  No.  2,  we  see  that  fever  seems 
to  be  so  little  either  the  effect  or  the  cause  of  the  redness  of  the  heart  and  vessels, 
that  this  redness  is  found  more  frequent  in  the  second  table,  containing  cases  of 
persons  who  died  without  fever. 

If  in  all  these  different  cases,  as  well  those  of  continued  fevers,  as  others,  we 
examine,  by  way  of  comparison,  the  redness  of  the  inner  surface  of  the  heart  and 
vessels,  we  find  it  always  the  same  : it  is  always  a uniform  colouring,  entirely 
different  from  the  numerous  shades  of  inflammatory  redness  observed  every- 
where else.  It  is  a colouring  similar  in  appearance  to  the  yellow  tint  presented 
after  death,  either  by  the  internal  surface  of  the  gall-bladder,  or  the  portion  of 
intestine  in  contact  with  it.  In  such  cases  the  vessels  never  presented  those  dif- 


164 


ANDltAL’S  MEDICAL  CLINIC. 


ferent  degrees  of  injection,  and  other  alterations,  which  M.  Gendrin  produced, 
either  on  their  internal  surface,  or  in  the  substance  of  their  tunics,  by  irritating 
those  organs  in  animals. 

Let  us  now  endeavour  to  appreciate  the  nature  of  the  changes  found  in  the 
heart  and  vessels  of  persons  who  have  died  of  continued  fevers,  and  let  us  strive 
to  determine  the  part  which  they  have  performed  in  those  diseases  of  similar 
morbid  changes. 

Those  changes  are  reducible  to  the  following  : — 

1.  Thickening  and  ulcerations  of  the  internal  membrane  of  the  veins  ; 

2.  Pus,  or  false  membranes  in  the  interior  of  these  vessels  ; 

3.  Diminution  of  the  heart’s  consistence  ; 

4.  Loss  of  colour  of  the  fleshy  substance  of  the  heart; 

5.  Redness  of  the  internal  surface  of  the  heart ; 

6.  Redness  of  the  internal  surface  of  the  arteries  ; 

7.  Redness  of  the  internal  surface  of  the  veins. 

The  thickening,  and  ulcerations  of  the  veins,  the  false  membranes  deposited 
on  their  internal  surface,  show  that  those  vessels  were  the  seat  of  a process  of 
irritation  ; in  this  process  it  might  be  the  origin  of  the  disease,  or,  at  least,  it 
might  have  its  share  in  causing  some  of  the  symptoms.  This  took  place  in  the 
case  cited  by  M.  Ribes  ; after  a gangrenous  phlegmon  of  one  of  the  hands, 
phlebitis  came  on,  then  ataxo-adynamic  symptoms,  in  the  midst  of  which  the 
patient  died  (delirium,  livid  countenance,  meteorism,  black  incrustations  of  the 
tongue  and  teeth,  &c.).  On  examining  the  body,  the  veins  were  found  filled 
with  pus,  their  parietes  thickened,  and  their  internal  surface  ulcerated.  M. 
Breschet,  more  recently  M.  Dance,  and  M.  Le  Gallois,  have  cited  cases  of 
phlebitis,  which  seemed  to  be  the  origin  of  the  adynamic  fever.  But  we  have 
no  hesitation  in  stating  that  out  of  one  hundred  cases  of  persons  who  have  died 
of  typhus  fever,  there  is  scarcely  one  found  where  the  veins  shall  present  any 
of  the  alterations  now  in  question. 

With  respect  to  the  cases  where  we  find  nothing  else  in  the  veins  but  pus 
mixed  with  blood,  that  is  no  proof  that  there  was  disease  of  these  vessels  ; for 
it  may  have  been  absorbed  by  them.  But  its  presence  in  the  blood  may  be  con- 
sidered as  producing  real  poisoning  ; the  result  of  which  may  be  the  symptoms 
of  adynamic,  putrid,  typhoid,  &c.,  fever.* 

Here,  then,  are  cases  wherein  the  changes  found  in  the  vessels  were  produced 
during  life,  and  performed  an  evident  part  in  the  symptoms. 

Let  us  now  try  whether  the  same  may  be  said  of  the  other  morbid  changes. 

Had  the  diminution  in  the  heart’s  consistence,  so  often  noticed  by  M.  Louis, 
any  share  in  the  production  of  the  disease  ? We  do  not  think  so  ; for  we  have 
found  it  in  several  other  cases,  where  the  individuals  having  died  of  the  most 
different  diseases,  whether  acute  or  chronic,  presented  no  symptom  of  typhoid 
fever.  Neither  do  we  think  that  we  can  attribute  this  diminished  consistence 
to  an  inflammatory  state  of  the  heart.  We  think  that  the  softening  of  the 
heart’s  tissue  is  very  frequently  a state  produced  only  after  death.  In  fact, 
almost  every  time  that  we  opened  the  bodies  of  persons  in  whom  there  were 
manifest  signs  of  putrefaction  a little  advanced,  we  found  the  tissue  of  the  heart 
remarkably  soft  ; it  was  so  friable,  that  very  slight  dragging  was  sufficient  to 
tear  it;  even  the  finger  could  be  forced  into  it  with  the  greatest  ease.  But 
there  are  bodies  in  which  putrefaction  commences  much  sooner  than  in  others  ; 
in  these  the  heart  may  be  found  very  soft,  though  the  examination  may  have 
been  made  only  a little  time  after  death.  This  cadaveric  softening  is  ordinarily 
accompanied  by  a livid  or  purple  redness  of  the  heart’s  tissue.  In  the  cases 


* This  point  of  doctrine  has  been  particularly  elucidated,  in  latter  times,  by  the  writings  of 
MM.  Ribes,  Gaspard,  Breschet,  Bouillaud,  Blandin,  Velpeau,  Gendrin,  Dance,  Le  Gallois. 


DISEASES  OF  THE  ABDOMEN. 


165 


where  it  may  be  supposed  that  a diminished  consistence  took  place  during  life, 
its  cause  escapes  us  ; and  far  from  considering  it  a lesion,  which  could  be  the 
origin  and  cause  of  the  symptoms,  we  might  be  rather  inclined  to  admit  that 
the  softening  is  one  of  the  products  of  this  same  disposition,  which,  with  any 
lesion  whatever,  produces  in  some  persons  the  state  called  adynamic  ; or  which, 
still  continuing  its  influence  after  the  termination  life,  liquefies  the  blood  pre- 
maturely. These  are  points  to  be  illustrated  by  new  researches.  Only  we 
shall  here  observe,  that  there  are  subjects  in  whose  body  there  is  found,  at 
one  and  the  same  time,  a singular  diminution  in  the  consistence  of  several  organs  : 
the  heart,  lungs,  liver,  spleen,  and  kidneys,  all  present  remarkable  friability  ; 
they  present  no  other  lesion,  and  it  is  no  longer  after  such  or  such  a disease, 
that  a similar  state  is  found.  We  have  cited  a very  remarkable  instance  of  this 
general  softening  in  a former  part  of  this  work. 

Neither  is  the  loss  of  colour  of  the  fleshy  substance  of  the  heart,  which  has 
been  observed  in  some  who  have  died  of  typhus  fever,  peculiar  to  this  kind  of 
disease,  and,  in  the  present  state  of  science,  we  cannot  assign  to  it  any  share  in 
the  production  of  some  of  the  symptoms  of  fever. 

We  have  already  seen  that  redness  of  the  inner  surface  of  the  heart  and  ves- 
sels may  be  met  in  an  almost  equal  proportion  after  all  diseases.  Let  us  see, 
however,  what  may  be  its  influence  on  fevers  ; for  this  purpose  let  us  study  its 
nature,  and  investigate  the  causes  of  its  development. 

The  following  table,  drawn  up  from  the  observations  of  MM.  Louis  and 
Bouillaud,  and  from  several  of  our  own,  will  present  at  first  a remarkable  coin- 
cidence between  the  frequency  of  redness  in  the  heart  and  vessels  in  the  differ- 
ent months  of  the  year,  and  the  elevation  of  temperature  in  these  months. 


Number  of  times  the  redness  was  found.  i 
January  . . . . .3 

February  ....  . 1 

March  . . . . .4 

April 3 

May 2 

June  .....  6 

July 9 I 

August  .....  14 

September  ...  . . 6 

October  ....  3 

November  . . . . . 2 ; 

December  . . . . 4 


Number  of  times  the  redness  was  not  found. 
January  . . . . .10 

February  ....  8 

March  .....  2 

April  .....  3 

May  .....  3 

June  .....  8 

July 3 

August  .....  4 

September  ....  2 

October  . 4 

November  ....  8 

December  . . . . 13 


On  considering  this  table,  it  will  be  found  that  during  the  four  months  when 
the  temperature  is  lowest  (November,  December,  January,  and  February), 
redness  of  the  vessels  has  been  observed  less  frequently  than  in  the  other  eight 
months  ; that  during  the  four  months  when  the  temperature  is  at  a mean  (Octo- 
ber, March,  April,  May),  this  redness  was  detected  more  frequently  than  in  the 
winter  months,  but  much  less  frequently  than  in  the  four  months  of  the  year 
when  the  temperature  is  most  raised  (June,  July,  August,  September),  and  yet 
in  these  four  last  months  the  redness  of  the  vessels  is  not  found  with  equal  fre- 
quency in  each.  The  months  of  June  and  September  present  less  cases  of  red- 
ness than  the  months  of  July  and  August,  and,  in  a word,  it  is  during  the  latter, 
which  is  in  general  the  hottest  month  of  the  year,  that  the  greatest  frequency 
of  vascular  redness  is  found. 

If  we  now  proceed  in  a similar  way  for  other  diseases  besides  fevers,  we  shall 
again  arrive  at  a similar  result ; and  we  shall  always  find  that  the  hottest 


166 


ANDRAL’S  MEDICAL  CLINIC. 


months  of  the  year  are  those  in  which  redness  is  most  frequently  found  on  the 
internal  surface  of  the  heart  and  arteries,  so  that  the  following  law  may  be  laid 
down  : — 

Whatever  may  have  been  the  disease  which  occasioned  death,  the  frequency 
of  vascular  redness  is  proportioned  to  the  elevation  of  temperature. 

This  law  includes  in  it  the  consequence  that  the  temperature  acts  a consider- 
able part  in  the  production  of  the  red  tint  of  the  heart  or  vessels. 

Still  mere  elevation  of  temperature  cannot  account  for  all  the  cases  wherein 
this  red  tint  is  found,  since,  on  the  one  hand,  it  is  present  in  cases  where  the 
dead  bodies  were  subjected  to  a very  low  temperature,  and,  on  the  other  hand, 
it  is  wanting  in  individuals  whose  bodies  were  examined  during  the  warmest 
months.  The  solution  of  the  problem  before  us  calls  for  the  introduction  of 
new  elements. 

One  of  the  most  important  of  these  elements  is,  no  doubt,  the  time  which 
elapsed  from  the  moment  of  death  to  the  time  when  the  body  was  examined. 

In  one  hundred  and  ninety-two  persons  who  died  of  continued  fevers  or  of 
other  diseases,  in  which  the  number  of  hours  that  elapsed  before  the  autopsy 
took  place  was  noted  by  us  or  by  others,  we  found  that  redness  or  paleness  of 
the  internal  surface  of  the  heart  or  vessels  was  distributed  in  the  following 
manner : — 


Time  which  had 
elapsed  since  the 
patient’s  death. 
Hours. 

10 

Cases  of 
redness. 

2 

Cases  of 
paleness. 

0 

Time  which  had 
elapsed  since  the 
patient’s  death. 
Hours. 

30 

Cases  of 
redness. 

9 

Cases  of 
paleness. 

2 

11 

0 

1 

31 

7 

0 

12 

0 

1 

32 

0 

0 

13 

0 

1 

33 

1 

1 

14 

0 

2 

34 

6 

2 

15 

1 

3 

35 

3 

0 

16 

0 

4 

36 

7 

2 

17 

0 

5 

37 

4 

0 

18 

1 

4 

38 

3 

0 

19 

1 

7 

39 

1 

0 

20 

1 

6 

40 

6 

0 

21 

1 

12 

41 

0 

0 

22 

1 

11 

42 

3 

0 

23 

3 

8 

43 

4 

1 

24 

6 

10 

45 

1 

0 

25 

2 

5 

46 

0 

0 

26 

2 

6 

47 

0 

0 

27 

2 

2 

48 

5 

0 

28 

6 

1 

53 

2 

0 

29 

3 

0 

60 

5 

0 

The  following  are  the  results  of  this  table  : we  find 


Cases  of  redness. 

Cases  of  paleness* 

In  the  first  2-4  hours  after  death 

17 

74 

From  24  hours  exclusive,  to  30  hours  inclusive 

24 

16 

From  30  hours  exclusive,  to  40  hours  inclusive 

38 

5 

From  40  hours  exclusive,  to  60  hours  inclusive 

20 

1 

These  results  induce  us  to  lay  down  the  following  law : — 

The  frequency  of  the  cases  wherein  redness  is  found  on  the  internal  surface 


DISEASES  OF  THE  ABDOMEN. 


167 

of  the  heart  or  vessels,  is  proportional  to  the  length  of  time  which  elapsed  from 
the  moment  of  death  to  the  moment  when  the  body  was  examined.* 

Combining  this  law  with  the  preceding,  we  come  to  the  conclusion  that  what- 
ever may  have  been  the  disease  and  the  kind  of  death,  the  frequency  with  which 
vascular  redness  is  observed  depends  on  the  greater  elevation  of  temperature  at 
the  time  the  body  is  opened,  and  on  the  length  of  time  that  has  elapsed  since 
the  patient  died. 

Still,  are  these  two  conditions,  which  act  only  by  favouring  the  development 
of  putrefaction,  the  only  ones  which  produce  the  red  colouring  of  the  heart  and 
vessels?  Certainly  not ; for  on  the  one  hand,  we  find  this  colouring  in  two 
bodies  which  were  opened  only  ten  hours  after  death  during  the  months  of  March 
and  December;  we  find  it  in  another  body  which  was  opened  fifteen  hours  after 
death  during  winter.  On  the  other  hand  we  find  this  same  red  colour  wanting  in 
a body  which  was  opened  forty-three  hours  after  death  in  the  month  of  June,  and 
in  two  other  bodies  which  were  opened  thirty-six  hours  after  death,  in  the 
months,  however,  of  November  and  January. 

How  shall  we  account  for  these  cases  ? Shall  we  say  that  the  redness,  which 
is  cadaveric  in  some,  is  not  so  in  others,  and  that  it  must  then  be  considered 
as  having  existed  during  life,  and  as  being  of  an  inflammatory  nature  ? Such 
a distinction  could  not  be  admitted  ; but  we  think  that,  according  to  the  nature 
of  the  disease  of  which  the  individuals  died,  as  also  according  to  the  kind  of 
death,  putrefaction  may  commence  at  very  variable  periods,  and  that  in  such 
cases  the  phenomena  which  announce  it  may  manifest  themselves  a very  few 
hours  after  death.  We  have  a striking  instance  of  this  in  our  47th  case.  One 
of  these  phenomena  is  the  spontaneous  separation  of  the  elements  of  the  blood, 
the  return  of  this  blood  to  the  liquid  state,  and  its  imbibition  by  the  solid  parts 
with  which  this  liquefied  blood  is  brought  in  contact. 

Thus,  then,  during  winter,  and  at  a period  not  far  distant  from  the  time  when 
death  took  place,  the  vessels  may  happen  to  be  found  coloured,  whether  the 
blood  which  they  contain  mayor  may  not  at  the  same  time  have  become  liquid. 
This  is  still  but  a cadaveric  phenomenon,  still  attributable  to  the  special  conditions 
in  which  the  nature  of  the  disease  consigned  the  subject  to  the  influence  of  phy- 
sical laws  at  the  time  when  life  was  extinct  in  him. 

With  respect  to  the  very  few  cases  in  which,  notwithstanding  the  length  of 
time  since  the  patient’s  death,  the  vessels  were  found  white,  we  must,  in  order 
to  account  for  them,  admit  a disposition  the  reverse  of  the  preceding,  in 
viriue  of  which  putrefaction,  far  from  being  advanced,  was,  on  the  contrary, 
retarded. 

It  may  also  be  remarked,  that  the  cadaveric  phenomenon  of  vascular  colouring 
is  not  the  only  one  which  thus  partly  depends  on  thfe  circumstances,  whether 
physical  or  organic,  in  the  midst  of  which  life  wa^extinguished.  Do  we  not,  for 
instance,  observe  varieties,  according  to  the  individuals,  in  the  colouring  of  the 
intestines  with  bile,  in  the  presence  of  serous  or  sanguineous  effusions  into  dif- 
ferent cavities,  etc.  ?f 

From  what  has  been  just  said,  we  shall  draw  the  following  corollaries  : — 

1.  The  red  tint,  which  is  occasionally  observed  on  the  internal  surface  of  the 
heart  and  vessels  in  persons  affected  with  continued  fevers,  performs  no  part  in 

* By  means  of  this  law  we  can  perfectly  account  for  the  very  small  number  of  times  that  we 
detected  redness  on  the  inner  surface  of  the  heart  or  vessels  in  the  cases  contained  in  the  pre- 
sent part  of  this  work.  Convinced  of  the  great  importance  of  opening  the  body  as  soon  as 
possible  after  death,  we  very  seldom  made  a post-mortem  after  twenty-four  hours,  and  very 
often  the  autopsy  took  place  before  this  time. 

-j-  By  these  different  facts,  the  law  laid  down  by  M.  Dutrochet  will  be  further  confirmed,  in 
virtue  of  which  exosmosis  has  a tendency  to  replace  endosmosis  every  time  that  a liquid  con- 
tained in  a cavity  has  a tendency  to  putrefy. 


1G8 


ANUIIAL’S  MEDICAL  CLINIC. 


the  production  of  some  of  these  fevers  ; it  does  not  even  concur  in  the  production 
of  any  of  their  symptoms. 

2.  This  red  tint  is  observed  indiscriminately  after  all  diseases,  after  those  ac- 
companied with  fever,  as  well  as  after  those  which  were  free  from  fever. 

3.  It  should  be  considered  as  a cadaveric  phenomenon,  the  more  or  less  rapid 
production  of  which  depends  on  certain  conditions,  which  may  all  be  resolved  into 
a single  one,  namely,  the  more  or  less  rapid  tendency  of  the  dead  body  to  putre- 
faction. 

The  blood  contained  in  the  heart  and  vessels  of  persons  who  have  died  of  bad 
continued  fevers  has  engaged  particular  attention  in  latter  times.  It  has  been 
said,  that  after  these  diseases  the  blood  has  been  usually  found  altered;  some- 
times, it  is  said,  the  clots  which  it  presents  are  remarkable  for  their  extreme 
softness  ; sometimes  these  clots  do  not  even  exist;  the  fibrin  is  now  observed 
in  the  form  of  small  fragments,  without  cohesion,  which  floats  scattered  through 
a reddish  serum  ; sometimes  these  fibrinous  fragments  disappear,  and  the  blood 
now  presents  everywhere  nothing  but  a completely  liquid  mass,  either  of  a deep 
black  colour,  or  of  a clear  rosy  tint,  resembling,  in  this  latter  case,  water  in 
which  a small  quantity  of  red  colouring  matter  was  dissolved. 

We  have  met  these  different  appearances  of  the  blood  in  several  bodies  of 
persons  who  died  with  the  symptoms  of  bad  fever  (Cases  8,  11,  13,  14,24,  25, 
29,  32,  47).  In  the  subject  of  the  14th  case,  the  heart  contained  clots  similar 
to  those  usually  found  in  dead  bodies,  but  the  liquid  contained  in  the  aorta  did 
not  resemble  blood ; it  was  a matter  having  the  colour  of  wine  lees,  as  it  were 
sanious  in  some  parts,  bearing  some  resemblance  to  the  unhealthy  fluid  contained 
in  some  abscesses. 

But  in  several  other  subjects  who,  during  life,  still  presented  symptoms  simi- 
lar to  the  preceding,  we  found  no  such  appearance  ; the  blood  contained  in  the 
heart  and  vessels  presented  the  appearance  observed  in  most  dead  bodies  ; it  con- 
sisted of  a clot  of  greater  or  less  consistence,  deprived,  or  not,  of  colouring 
matter. 

If  we  now  enquire  what  are  the  different  appearances  which  the  blood  presents 
in  the  bodies  of  persons  who  have  died  of  other  diseases  besides  bad  fevers,  we 
shall  also  find  that,  in  those  diseases,  whatever  may  have  been  their  nature,  the 
heart  and  vessels  occasionally  contain  a liquid  dissolved  blood,  like  the  blood  of 
some  typhoid  fevers  ; and  we  think,  that  if  the  number  of  the  cases  where  the 
blood  presented  this  appearance  appears  to  be  greater  in  typhoid  fevers  than  in 
other  diseases,  it  is  because  more  particular  attention  has  been  paid  to  this  point 
in  fevers. 

For  our  own  part,  we  shall  say  that,  since  we  applied  ourselves  to  the  exami- 
nation of  the  blood  in  all  dead  bodies,  we  have  several  times  found  it  in  a liquid 
state  in  every  species  of  disease  ; and  to  speak  only  of  the  cases  contained  in 
this  present  part,  it  will  be  recollected  that  such  was  the  state  of  the  blood  in  the 
individual  affected  with  tetanus,  who  forms  the  subject  of  Case  30. 

Thus,  then,  in  continued  fevers,  the  cases  in  which  the  blood  is  found  percep- 
tibly changed  are  not  more  numerous  than  those  wherein  the  blood  presents  what 
we  consider  its  normal  state  ; the  cases  of  fevers  where  this  liquid  appears  altered 
differ  in  no  respect  with  regard  to  the  symptoms  from  those  wherein  it  appears 
not  to  be  so  ; and,  in  a word,  similar  alterations  of  the  blood  are  observed  after 
other  diseases  which  bear  no  resemblance  whatever  to  typhoid  fevers. 

Among  the  cases  wherein  the  blood  is  found  liquid  in  the  vessels  there  are 
some  in  which  this  liquid  state  coincides  with  different  signs  of  putrefaction. 
We  then,  at  the  same  time,  find  the  parietes  of  the  heart  softened,  and  a red 
tint  is  observed  on  its  internal  surface,  as  also  on  that  of  the  vessels.  This 
liquid  state  of  the  blood  is  likewise  more  frequently  met  when  the  bodies  are 
opened  during  an  elevated  temperature,  and  a long  time  after  death.  However, 


DISEASES  OF  THE  ABDOMEN. 


169 


there  are  other  cases  where  this  is  not  the  case  ; then  it  must  be  admitted  that 
causes  inherent  in  the  subject  himself  prevented  the  blood  from  coagulating  in 
the  dead  body,  or,  after  it  had  coagulated,  accelerated  its  return  to  the  liquid  state. 
We  have  sometimes  found  the  internal  surface  of  the  vessels  white,  notwithstand- 
ing the  liquid  state  of  the  blood  which  was  in  contact  with  it.  But  we  think 
it  probable  that,  in  cases  of  this  kind,  the  vessel  would  have  been  found  coloured, 
if  the  body  had  been  opened  at  a later  period. 

If,  with  respect  to  the  state  of  the  blood  in  persons  who  died  of  continued 
fevers,  we  compare  our  own  observations  with  those  of  some  other  authors,  we 
shall  find  that  they  have  obtained  results  similar  to  ours.  Thus,  in  the  Observa- 
tions on  Entero-Mesenteric  Fever,  published  by  MM.  Petit  and  Serres,  there 
is  no  mention  of  the  liquid  state  of  the  blood,  though  in  all  these  cases  the  state 
of  the  heart  was  carefully  noted.  Neither  has  M.  Trousseau  noticed  this  liquid 
state  in  the  cases  of  Dothinenterite  which  he  has  published.  M.  Bouillaud,  who 
admits,  in  a general  way,  that  in  bad  fevers  the  blood  is  found  to  be  liquid  and 
dissolved,  has,  however,  met  this  state  of  the  blood  only  in  three  cases  in  fifteen 
cases  of  putrid  fever  detailed  in  his  work.  Among  the  fifty-four  cases  of  M.  Louis 
there  are  but  three  where  mention  is  made  of  the  liquid  state  of  the  blood  ; and 
the  well-known  accuracy  of  this  physician  is  a sufficient  guar  antee  that,  if  he  had 
met  it  oftener,  he  would  not  have  failed  to  mention  it. 

We  therefore  think  we  may  lay  it  down  that,  in  the  present  state  of  sci- 
ence, the  part  ascribed  to  the  blood  in  the  production  of  a certain  number  of  bad 
fevers  may  be  much  better  proved,  either  by  the  nature  of  the  external  influences 
which  have  acted  on  the  individuals,  or  sometimes  by  the  nature  of  the  symp- 
toms themselves,  than  by  the  existence  of  those  changes  in  the  blood  discovera- 
ble by  anatomy.  Let  us  not  again  compromise  the  cause  of  humourism  by  re- 
quiring from  the  facts  within  its  domain  more  than  they  are  yet  able  to  give.* 

The  spleen,  of  which  we  shall  here  speak  as  being  a probable  dependent  on 
the  circulating  apparatus,  is  one  of  the  parts  which  has  been  most  frequently 
found  changed  in  individuals  who  have  died  of  continued  fevers.  In  the  great 
majority  of  cases  we  found  it  at  one  and  the  same  time  perceptibly  increased  in 
size,  and  very  much  softened.  By  gently  pressing  it  under  a stream  of  water, 
there  was  forced  from  it  a considerable  quantity  of  a substance  resembling  wine 
lees,  and  by  thus  reducing  the  spleen  to  its  parenchyma,  which  was  not  changed, 
it  was  restored  to  its  natural  size.  Its  increase  in  bulk  then  depended  on  the 
unusually  increased  quantity  of  matter  contained  in  its  cells,  as  its  soft  state  was 
owing  to  the  diminished  consistence  in  the  same  substance. 

In  one  case  only  have  we  found  the  spleen  both  softened  and  small  in  size. 

In  another  instance,  we  saw  it  very  small,  and  very  dense.  We  have  some- 
times found  the  spleen  in  its  normal  state,  both  with  respect  to  its  size  and  con- 
sistence. 

Thus  the  very  remarkable  alterations  of  the  spleen  in  continued  fevers,  are 
almost  as  frequent  as  the  intestinal  alterations  are  in  these  same  diseases;  but 
they  are  not  more  constant  than  the  latter,  whatever  be  their  extreme  fre- 
quency. 

The  most  ordinary  lesion  presented  by  the  spleen  in  continued  fevers,  namely, 
increase  of  size  with  softening  of  its  tissue,  is  not  connected  with  the  existence 
of  dothinenterite.  We  have  met  it  without  there  being  in  the  intestine  any  trace 
of  an  affection  of  the  follicles,  but  merely  an  intestinal  erytheme. 

We  have  also  observed  increase  in  the  size  of  the  spleen,  with  softening  of 
its  tissue,  in  several  other  cases  where  the  digestive  tube  was  perfectly  healthy, 
and  where  the  typhoid  symptoms  had  their  origin  and  cause  elsewhere. 

* We  should  not,  however,  forget  that  the  experimentalists,  who  injected  putrid  substances 
into  the  veins  of  animals,  say  that  they  found  the  blood  in  a liquid  state. 

15 


170 


ANDRAL’S  MEDICAL  CLINIC. 


On  the  other  hand,  two  cases  presented  the  spleen  in  its  normal  3tate,  though 
the  small  intestine  was  ulcerated,  and  the  mucous  membrane  of  the  stomach  was 
red  in  one  case,  and  brown  in  the  other. 

Neither  is  softening  of  the  spleen,  with  increase  in  its  size,  connected  with 
certain  states  of  the  blood.  Whatever  the  appearance  of  the  latter  was,  we  found 
the  same  lesion  in  the  spleen. 

This  lesion  forms  from  the  very  commencement  of  the  disease  ; thus  M.  Louis 
found  the  spleen  soft  and  large  in  two  individuals,  one  of  whom  died  on  the  8th, 
and  the  other  on  the  tenth  day  of  the  disease.  We  also  detected  the  existence 
of  this  lesion  in  an  individual  who  died  on  the  11th  day.  On  the  other  hand, 
we  also  found  it  in  persons  who  died  at  all  periods  of  the  disease,  even  up  to 
the  forty-sixth  day.  It  would  appear  from  the  researches  of  M.  Louis,  that  the 
spleen  was  more  frequently  found  large  and  soft,  in  persons  who  die  before  the 
thirtieth  day,  than  in  those  who  die  after  this  period. 

Again,  it  is  not  only  in  persons  who  die  of  bad  fevers,  with  or  without  mor- 
bid alteration  of  the  digestive  passages,  that  the  spleen  is  found  to  be  much  softer 
than  seems  to  be  compatible  with  its  normal  state.  We  have  found  this  same  soft 
state  carried  to  an  extreme  degree,  in  the  bodies  of  individuals  who  died  of  dis- 
eases of  the  most  different  characters,  with  fever  or  without  fever,  and  in  whom 
no  particular  symptom  had  indicated  softening  of  the  spleen.  But  what  appears 
satisfactorily  proved  is  this,  that  this  organ  is  not  found  softened  in  any  disease 
as  frequently  as  in  continued  fever ; more  particularly  in  none  is  it  found  so  fre- 
quently increased  in  size. 

In  the  present  state  of  science,  we  can  offer  only  mere  conjecture  with  re- 
spect to  the  cause  which,  in  continued  fevers,  thus  diminishes  the  normal  con- 
sistence of  the  spleen,  at  the  same  time  that  it  increases  its  size.  We  cannot 
say  more  regarding  the  nature  of  this  lesion.  We  shall  only  remark,  that  Dr. 
Bailly  has  also  ascertained  its  existence  in  individuals  who  died  during  the 
accession  of  bad  intermittent  fevers,  whatever  may  have  been  the  prevailing 
symptoms  of  this  fever.  We  may  now  observe,  that  so  frequent  a lesion  should 
not  be  lost  sight  of,  every  time  we  endeavour  to  trace  the  causes  and  nature  of 
fevers. 

The  physician  just  mentioned  has  published  several  cases  of  bad  intermit- 
tents,  where  the  softening  of  the  spleen  was  carried  so  far  that  this  organ  was 
actually  torn.  We  have  observed  this  spontaneous  rupture  of  the  spleen  only 
once,  and  that  in  the  case  of  an  individual  who  had  had  follicular  enteritis  with 
typhoid  symptoms.  This  man,  who  was  twenty-five  years  of  age,  died  at  the 
Pitie,  after  being  nine  or  ten  days  ill ; it  was  remarked,  that  a few  hours  before 
dying,  he  suddenly  began  to  sink ; on  the  preceding  day,  in  the  midst  of  his 
delirium,  he  had  fallen  from  his  bed  on  the  floor. 

We  found  several  pounds  ( livres ) of  black,  liquid  blood,  eflused  into  the  pe- 
ritoneum : we  instantly  examined  whether  some  large  vessels  had  not  been  rup- 
tured ; we  discovered  no  alteration  in  any  of  them  ; but  the  spleen  presented, 
on  its  external  surface,  two  oblong  rents,  through  which  the  blood  contained  in 
this  organ  seemed  to  have  escaped,  so  as  to  fill  the  peritoneum.  This  spleen, 
which  was  very  large,  was  reduced  to  a real  black  softish  substance,  by  the 
slightest  pressure.  We  reckoned  in  the  intestine  forty  elliptical  patches,  all 
projecting  above  the  level  of  the  mucous  membrane  ; only  one  of  them  was 
commencing  to  ulcerate.  Between  them  the  pale  mucous  membrane  was  tra- 
versed by  a great  number  of  solitary  cryptae,  very  much  developed.  These  same 
cryptae  existed  in  the  large  intestine.  The  mucous  membrane  of  the  stomach 
presented  a brightred  pointing  through  the  entire  extent  of  the  great  cul-de-sac  ; 
in  every  part  where  it  was  red,  it  was  softened. 


DISEASES  OF  THE  ABDOMEN* 


171 


SECTION  II 

LESIONS  OF  THE  CIRCULATORY  APPARATUS  OBSERVED  DURING  LIFE. 

The  functional  disturbances  of  the  circulator}'  apparatus,  generally  com- 
prised under  the  generic  term  fever,  will  be  better  studied,  and  better  known, 
if,  as  we  have  done  elsewhere,  with  respect  to  the  term  inflammation we 
consider  separately  and  distinctly  each  of  the  phenomena  which  concur  with 
others  in  the  production  of  the  complex  and  indeterminate  state  called  fever. 

The  pulsations  of  the  heart  in  our  patients  presented  nothing  but  different  de- 
grees of  frequency  and  strength,  always  proportioned  to  the  different  degrees  of 
frequency  and  strength  in  the  pulse. 

The  circumstances  to  be  studied  in  the  arterial  pulsations  are:  1st,  their 
strength  ; 2d,  their  frequency  ; 3d,  their  regularity. 

Nothing  was  more  variable  in  our  patients  than  the  strength  of  the  pulse. 
Sometimes  from  the  very  commencement  of  the  affection,  it  was  small,  and  ex- 
tremely compressible.  At  other  times  it  retained  considerable  resistance  up  to 
the  moment  of  death,  and  gave  a sensation  of  fulness  to  the  finger  which  pressed 
it.  In  some  of  our  patients  we  saw  life  cease,  when  the  pulsations  of  the  artery 
had  still  considerable  strength.  In  several  individuals,  the  pulse  was  neither 
stronger  nor  weaker  than  in  the  ordinary  state  of  health.  In  general,  possessing 
considerable  strength  and  fulness  at  the  commencement  of  the  disease,  it  conti- 
nually became  weaker  and  more  compressible,  according  as  the  adynamic  symp- 
toms became  more  marked.  However,  in  a considerable  number  of  cases,  the 
strength  of  the  arterial  pulsations  formed  a striking  contrast  with  the  state  of 
prostration  into  which  the  patients  appeared  to  have  fallen.  In  several  the  pulse, 
very  weak  at  certain  times  of  the  day,  was  raised,  and  acquired  considerable 
strength,  particularly  towards  night. 

The  frequency  of  the  pulse  was  found  to  be  increased  in  the  great  majority  of 
cases  : it  was  generally  more  considerable  at  night.  When  this  frequency  is  such 
as  not  to  exceed  from  ninety-five  to  one  hundred  and  twenty  pulsations  in  the 
minute,  this  sign,  separately  considered,  should  incline  one  to  form  a favourable 
prognosis.  This  prognosis,  on  the  contrary,  becomes  very  unfavourable,  if  the 
arterial  pulsations  exceed  one  hundred  and  forty  per  minute,  and  particularly  if 
their  frequency  has  not  diminished,  or  has  increased  after  several  abstractions  of 
blood. 

In  the  great  majority  of  our  patients,  the  pulse  becomes  frequent  only  a longer 
or  shorter  time  after  their  health  has  commenced  to  be  deranged ; in  some,  the 
acceleration  in  the  circulation  was  preceded  by  mere  general  illness,  without  any 
local  functional  disturbance  that  was  at  all  perceptible  ; sometimes,  and  this  case 
was  more  usual  than  the  preceding,  there  were  different  symptoms  referrible  to  the 
digestive  organs,  and  particularly  diarrhoea. 

In  other  patients,  the  accelerated  circulation,  accompanied  with  elevation  of 
the  skin’s  temperature,  preceded  every  other  morbid  phenomenon,  and  it  was  to 
no  purpose  then  that  one  should  endeavour,  by  interrogating  only  the  symp- 
toms, to  seek  the  cause  of  this  disturbance  of  the  circulation  in  the  suffering 
of  any  organ  ; this  febrile  disturbance  continued  thus,  distinct  from  every  other 
apparent  disorder,  for  between  twenty-four  to  fifty  hours  : then  local  disturb- 
ances came  on,  and  they  were  almost  invariably  directed  towards  the  primae 
viae. 

In  others  the  accelerated  circulation,  with  increased  heat  of  skin,  and  without 
any  other  apparent  local  disturbance,  continued  for  a much  longer  time,  and  after 


* Pathological  Anatomy, 


172 


ANDRAL’S  MEDICAL  CLINIC. 


having  lasted  for  several  days,  the  fever  ceased  without  our  being  able  to  detect 
in  the  system  any  other  lesion  than  the  fever  itself.  However,  we  must  not  forget 
that  in  some  cases  of  this  kind  which  terminated  fatally,  we  found  in  the  intestine 
traces  ofan  acute  affection  of  the  follicles.  In  these  numerous  cases  of  slight  fevers, 
without  any  appreciable  local  disturbance,  and  which  terminated  in  a return  to 
health,  did  this  terminatic/n  take  place  spontaneously  and  merely  by  adopting 
an  expectant  mode  of  treatment,  or  in  consequence  of  a shock  being  given  to  the 
system  either  by  emetics  or  bleeding  ? We  certainly  would  not  say  so  ; and  in 
this  case,  till  more  ample  information  be  obtained,  is  it  not  strictly  conformable 
to  the  true  scientific  spirit  to  give  a denomination  derived  from  the  symptoms  to 
a disease,  the  organic  cause  of  which  can  frequently  be  only  suspected  or  ad- 
mitted by  an  analogy,  which  is  any  thing  but  accurate,  since  it  is  not  to  be  doubted 
that  what  are  called  essential  fevers  may  have  their  seat  elsewhere  as  well  as  in 
the  digestive  tube  ? 

Lastly,  in  several  patients  we  have  seen  all  the  local  symptoms  disappear, 
and  yet  the  febrile  disturbance  still  continue  for  some  days.  Has  all  local  lesion 
disappeared  then,  or  does  it  still  continue,  but  indicates  itself  only  by  the  dis- 
turbance of  the  circulation  ? We  would  be  more  inclined  to  admit  this  second 
hypothesis  ; and  to  give  it  some  weight,  we  would  refer  to  those  cases  of  pneu- 
monia, which  at  a certain  period  of  their  existence,  are  indicated  only  by  fever, 
all  the  local  symptoms  having  completely  disappeared.  In  these  cases,  before 
percussion  and  auscultation  were  understood,  it  would  have  been  said  that  the 
fever  survived  the  pulmonary  lesion  ; and  yet,  though  there  is  then  neither 
cough,  nor  dyspnoea,  nor  expectoration,  nor  thoracic  pain,  auscultation  shows 
that  the  lung  is  far  from  having  returned  to  its  normal  state. 

We  must  distinguish  the  case  of  which  we  have  now  spoken  from  that  where, 
after  the  disappearance  of  all  the  symptoms,  no  other  irregularity  .is  observed 
except  mere  frequency  of  the  pulse,  which  is  oftentimes  connected  with  the 
state  of  convalescence,  which  is  kept  up  by  continuing  meagre  diet  for  too  long 
a time,  and  which  disappears  according  as  the  patient  takes  nourishment  and 
recovers  strength. 

The  pulsations  of  the  heart  and  arteries,  instead  of  being  accelerated,  become 
remarkably  slow  in  some  of  our  patients  ; or  else,  in  the  midst  of  the  most 
alarming  symptoms,  they  scarcely  deviate  from  their  normal  state.  We  have 
principally  observed  this  natural  state  of  the  pulse,  or  its  slow  state,  in  cases 
where  the  nervous  symptoms  predominated.  It  has  served  us,  in  several  cases, 
to  distinguish  a fever  which  had  its  origin  in  the  brain  from  another,  the  organ 
of  which  was  in  the  digestive  tube.  However,  even  in  this  latter  case,  and 
with  the  existence  of  a dothinenterite,  it  may  happen  that  there  will  be  a slow 
pulse. 

Slowness  of  the  pulse  in  persons  labouring  under  bad  fevers  has  been  noticed 
by  several  observers,  and  they  have  generally  considered  it  as  a very  unfavour- 
able sign.  But  what  they  have  not  stated,  and  what  we  have  several  times  ob- 
served, is,  that  certain  individuals,  whose  pulse  had  been  frequent  during  the 
entire  course  of  the  disease,  present  remarkable  slowness  of  the  pulse  at  the 
time  of  their  convalescence.  One  person,  among  others,  had  had  all  the  symp- 
toms of  what  is  called  adynamic  fever.  At  the  time  when  he  might  be  consi- 
dered as  completely  convalescent,  the  pulse  which  had  gradually  lost  its  morbid 
frequency,  became  all  at  once  very  slow  : for  some  days  it  was  but  from  36  to 
38  per  minute  ; it  then  rose  to  40,  then  to  50  ; and  when  the  individual  left  the 
hospital  in  a very  good  state  of  health,  his  pulse  was  from  70  to  72,  which 
was  proportioned  to  his  age  and  constitution. 

We  havebut  seldom  observed  irregularity  of  the  pulse  ; in  the  cases  in  which 
it  took  place,  we  have  not  seen  that  this  character  of  the  pulse  exercised  any 
influence  on  the  other  symptoms,  on  the  progress  of  the  disease,  on  its  severity, 


DISEASES  OF  THE  ABDOMEN. 


173 


or  on  its  termination.  In  one  of  the  cases  in  which  we  found  the  pulse  irregu- 
lar, there  was  a great  quantity  of  worms  in  the  digestive  tube.  One  patient 
presented  to  us  a curious  anomaly  : his  pulse,  irregular  as  long  as  the  affection 
was  slight,  became  regular  according  as  the  symptoms  became  unfavourable. 
In  another,  the  pulse,  after  having  presented  the  greatest  regularity  during  the 
entire  course  of  the  disease,  became  irregular  during  convalescence.  Every 
time  we  found  the  pulse  irregular  in  persons  labouring  under  continued  fever, 
we  have  been  inclined  to  suspect  that  this  irregularity  depended  less  on  the  dis- 
ease then  present  than  on  an  organic  lesion  of  the  heart,  and,  on  seeking  for 
the  latter,  we  have  frequently  detected  its  existence  in  such  cases. 

The  modifications  which  the  pulse  undergoes  in  point  of  frequency,  almost 
always  bring  with  them  some  modification  in  the  temperature  of  the  skin. 

Most  frequently,  in  continued  fevers,  an  increase  in  the  frequency  of  the 
pulse  is  accompanied  by  an  increase  in  the  heat  of  the  skin but  we  do  not 
always  observe  a strict  relation  between  an  acceleration  of  the  circulation  and 
increase  of  temperature.  The  heat  may  be  very  intense  in  cases  where  the  fre- 
quency of  the  pulse  is  but  moderate  ; this  heat  may,  on  the  contrary,  be  scarcely 
developed  in  other  cases  where  the  pulse  has  become  extremely  frequent. 

More  frequently  than  in  any  other  disease,  increased  heat  of  skin  coincides 
in  bad  fevers  with  a peculiar  dryness  of  this  membrane.  It  is  in  these  affec- 
tions principally  that  we  observe  that  acrid  heat  in  which  the  skin  at  times 
cannot  be  touched  even  for  a few  moments  in  succession  without  experiencing 
any  uneasy  sensation,  and  sometimes  jven  real  pain. 

In  the  greater  number  of  patients  the  increase  in  the  skin’s  heat  becomes 
more  considerable  towards  evening.  What  particularly  struck  us  in  some  was 
a great  inequality  in  the  distribution  of  the  heat.  In  others,  one  and  the  same 
part  presented  for  some  hours  the  most  rapid  alternations  of  an  almost  icy  cold- 
ness and  extreme  heat. 

Increase  in  the  temperature  of  the  skin  does  not  necessarily  follow  every 
intestinal  irritation,  however  intense  the  latter  may  be  ; we  have  seen  cases  of 
dothinenterite  of  a very  acute  form,  and  which  reached  the  stage  of  ulceration, 
when  death  supervened,  in  which,  however,  the  temperature  of  the  skin  always 
remained  natural.  We  have  seen  among  others  a striking  instance  of  this  in 
the  young  girl  who  forms  the  subject  of  our  18th  case.  In  her,  the  intestines 
were  found  very  much  ulcerated,  and  yet  it  was  only  forty-eight  hours  before 
death  that  she  presented  any  heat  of  skin.  In  this  patient  nervous  symptoms 
chiefly  predominated  ; during  life  everything  seemed  to  indicate  thqj  the  seat 
of  the  disease  was  in  the  encephalon,  or  rather  in  its  membranes ; still  it  was 
only  in  the  intestines  that  any  lesion  was  detected.  From  this  fact  we  shall 
draw  the  conclusion  that  absence  of  heat  of  skin  in  an  individual  who  presents 
the  symptoms  of  what  is  called  ataxic  fever,  is  not,  as  has  been  stated  by  some, 
a sufficient  reason  for  asserting  that  the  disease  has  not  had  its  primary  seat  in 
the  digestive  passages. 

Though  in  most  cases  the  heat  of  skin  disappears  some  hours  before  death,  we 
have  seen  instances  in  which  life  ceased  at  a lime  when  the  temperature  of  the 
skin  was  very  high  ; we  have  seen  other  cases  in  which  it  was  only  during  the 
last  days  of  existence  that  the  skin  was  hot. 

The  diminution  in  the  temperature  of  the  skin  may  appear  under  different  - 
forms,  and  at  different  periods  of  the  disease.  First,  in  several  cases,  the  com- 
mencement of  the  disease  is  ushered  in  by  that  sensation  of  cold  which  consti- 
tutes shivering.  After  some  moments  or  some  hours,  it  is  succeeded  by  heat, 
and  does  not  reappear.  But  this  shivering  at  the  commencement  of  the  disease 
is  very  frequently  entirely  absent. 

Whether  the  disease  may  have  commenced  by  shivering,  or  whether  it  comes 
on  only  after  some  days  of  general  illness,  namely,  headach,  loss  of  appetite,  and 
15* 


174 


ANDRAL’S  MEDICAL  CLINIC. 


even  diarrhoea,  or  whether  the  fever  may  have  set  in  without  having  been  pre- 
ceded by  any  shivering,  it  happens,  in  some  cases,  that  during  the  course  of  the 
disease  the  shivering  appears  periodically,  most  commonly  towards  evening; 
sometimes  every  day,  sometimes  only  every  two  days.  This  shivering  is  fol- 
lowed by  an  intense  heat,  and  the  latter  is  succeeded  often,  but  not  always,  by 
sweat  more  or  less  profuse.  These  accessions  may  be  renewed  a certain  num- 
ber of  times,  they  then  cease,  and  the  disease  assumes  a simple  continued  form. 
We  have  seen  these  accessions  disappear  after  the  employment  of  the  most 
opposite  means,  sometimes  bloodletting,  sometimes  quinquina,  sometimes 
emetics  ; at  other  times  we  have  seen  them  disappear  spontaneously,  after  the 
patient  had  continued  for  some  days  in  the  hospital. 

In  the  greater  number  of  our  patients  we  observed  no  alarming  symptom  to 
accompany  the  return  of  these  accessions  ; in  others  they  resembled  genuine 
accessions  of  malignant  fever.  In  one  of  these  cases  the  return  of  these  acces- 
sions seemed  to  be  prevented  by  the  administration  of  quinquina  in  the  form 
of  lavement : in  another  case  this  means  was  not  resorted  to,  and  death  took 
place  after  the  third  accession. 

In  persons  labouring  under  bad  fevers  other  forms  of  cold  are  observed  which 
no  longer  resemble  the  shivering  or  febrile  accession.  We  then  observe  the 
skin  suddenly  lose  its  heat,  either  over  its  entire  extent  or  in  some  parts  only, 
and  present  a cadaveric  cold  feel,  which  sometimes  continues  till  death,  and  is 
sometimes  followed  by  the  return  of  heat.* 

We  have  seen  some  patients  in  whom  the  continued  fever  had  been  preceded 
by  fits  of  intermittent  fever.  We  have  seen  other  patients  in  whom  intermittent 
fever  came  on  during  convalescence  from  continued  fever. 

One  of  these  patients  was  a girl  16  years  of  age.  When  she  entered  the 
Charite  she  had  a slight  continued  fever,  which  yielded  to  strict  regimen  and 
rest.  Being  convalescent  for  a little  time  she  did  not  recover  strength  ; her 
countenance  was  very  pale  ; she  felt  at  intervals  transient  shiverings  followed 
by  heat,  but  never  by  sweat.  Sometimes  these  attacks  appeared  only  every 
four  or  five  days,  sometimes  they  returned  several  times  on  the  same  day.  The 
patient  continued  in  this  state  for  three  weeks.-  At  the  end  of  this  time  she  had 
six  regular  fits  of  tertian  fever,  the  return  of  the  seventh  was  prevented  by  the 
employment  of  quinquina.  The  patient  soon  left  the  hospital  in  good  health. 

The  other  patient,  convalescent  from  an  inflammatory  fever,  was  preparing 
to  leave  the  hospital,  when,  without  any  known  cause,  he  was  attacked  with 
a well-mgrked  tertian  fever.  It  was  cut  short  by  quinquina,  after  the  sixth  fit. 

A third  patient  was  also  labouring  under  a continued  fever  when  he  entered  - 
the  hospital.  After  about  ten  days,  the  pulse  being  but  of  moderate  frequency, 
a violent  shivering,,  followed  by  heat  and  sweat,  took  place  in  the  afternoon. 
Three  similar  fits  reappeared  on  the  following  days,  under  the  ter'tain  type.  In 
the  intervals  between  the  fits  there  was  complete  apyrexia.  This  intermittent 
fever  ceased  spontaneously  after  the  fourth  paroxysm. 

We  have  already  seen  the  appearance  of  the  blood  after  death,  both  in  the 
heart  and  vessels.  Let  us  now  recapitulate  the  results  of  our  observations  with 
respect  to  the  qualities  of  this  same  blood  when  drawn  from  the  vein  during 
life. 

Out  of  a great  number  of  cases  of  venesections  in  which  the  slate  of  the  blood 

* The  cadaveric  coldness  is  not  invariably  an  infallible  sign  of  death.  We  had  recently  an 
opportunity  of  seeing  an  individual  labouring  under  a chronic  affection  of  the  stomach,  in 
whom,  two  months  at  least  before  death,  the  skin  was  so  very  cold  three  or  four  times,  that 
one  would  imagine  that  he  was  touching  a dead  body.  At  the  same  time  the  pulse  was  gone, 
and  the  respiration  became  almost  imperceptible  ; the  patient  seemed  in  the  last  struggle. 
This  state  continued  for  twenty  hours,  then  the  skin  became  hot  again,  the  circulation  was  re- 
established, and  the  individual  returned  to  his  natural  state. 


DISEASES  OF  THE  ABDOMEN. 


175 


is  described,  we  find  but  twelve  in  which  the  blood  presented  a buffy  coat, 
which  was  rarely  thick  and  dense,  but  most  frequently  thin  and  soft.  Among 
these  two,  who  had  the  vein  opened  twice,  yielded  blood  which  presented  no 
buffy  coat  the  first  time,  and  buffed  blood  the  second  time.  In  one  of  these 
there  was  nothing  to  account  for  this  difference  in  the  appearance  of  the  blood 
at  the  two  bleedings.  In  the  other  the  second  bleeding  was  employed  to  combat 
a pneumonia  which  had  come  on  during  convalescence  ; but  every  time  there 
was  a complication  of  pneumonia,  still  no  buffy  coat  was  observed.  Then  the 
individual  who  forms  the  subject  of  the  first  case  was  bled  three  times  ; the 
third  bleeding,,  which  was  resorted  to  during  the  existence  of  a pneumonia,  was 
not  more  buffed  than  the  other  two. 

In  several  patients  the  crassamentum  was  remarkable  for  its  great  softness, 
and  for  the  total  absence  of  retraction. 

In  others  the  blood  drawn  from  the  vein  presented  an  appearance  which  indi- 
cated a more  marked  change  of  this  fluid.  Thus  in  the  subject  of  our  seven* 
teenth  case,  the  blood  resembled  currant  jelly;  and  it  was  in  this  same  case 
that  the  aorta  was  found  after  death  filled  with  a peculiar  sanious  sort  of  blood 
already  described.  The  blood  was  not  less  changed  in  one  of  the  individuals 
affected  with  small-pox,  whose  case  has  been  given  ; beneath  a very  thick  buffy 
coat  w.e  found  no  trace  of  crassamentum,  but  only  a sort  of  lees  formed  by  the 
intimate  fusion  of  the  different  elements  of  the  blood.  The  existence  of  the 
inflammatory  buffy  coat  with  such  a dissolved  state  of  the  blood  seems  to  us 
very  remarkable. 

This  is  all  that  we  remarked  worthy  of  notice  in  the  blood  drawn  from  the 
veins  of  persons  labouring  under  continued  fever,  whether  slight  or  severe. 
When  observed  during  life,  this  blood  did  not  then  present  any  more  constant 
alteration  than  the  blood  of  those  same  diseases  observed  after  death.  The  only 
three  cases  in  which  we  observed  the  blood  really  altered,  did  not  present  in 
the  symptoms  anything  but  what  occurred  in. the  other  cases,  but,  further,  we 
found  similar  alterations  in  the  blood  of  individuals  labouring  under  diseases 
totally  distinct  from  what  are  called  essential  fevers. 

Since  the  cases  detailed  in  this  volume  were  collected,  we  have  had  frequent 
opportunities  of  submitting  to  an  attentive  examination  the  blood  taken  from 
the  veins  of  persons  labouring  under  all  the  varieties  of  essential  fever.  All  that 
we  ascertained  is  the  rare  occurrence  of  the  buffy  coat,  and  the  great  softness  of 
the  crassamentum.  With  respect  to  this  buffy  coat  itself,  the  causes  which, 
out  of  ten  cases  of  continued  fevers,  produce  it  once,  and  occasion  its  absence 
nine  times,  do  not  appear  to  us  capable  of  being  discovered,  except  wlien  there 
comes  on  a complication  of  pneumonia,  pleuritis,  or  rheumatism. 

Neither  has  M.  Louis  found  any  thing  particular  in  the  blood  drawn  from  the 
veins  of  persons  affected  with  typhoid  fever  ; as  was  the  case  with  us,  he  found 
the  buffy  coat  in  only  a small  number  of  cases  of  bloodletting,  thirteen  times 
out  of  forty. 

After  these  facts,  which  are  sufficiently  numerous  to  warrant  us  in  attach- 
ing some  value  to  them,  it  is  with  some  reserve  that  we  shall  admit  of  other 
facts,  observed  at  different  periods,  from  which  it  would  appear  that  nothing  is 
more  common  than  to  find  the  blood  changed  in  persons  bled  during  the  pro- 
gress of  a bad  fever.  We  shall  repeat  here  what  we  have  already  laid  down  as 
a consequence  of  those  researches  into  the  blood  examined  after  death  ; it  is 
this,  that  if  in  these  diseases  there  exist  an  alteration  of  the  blood,  it  is  most 
frequently  not  to  be  appreciated  by  our  senses. 


176 


ANDRAL’S  MEDICAL  CLINIC. 


APPARATUS  OF  THE  LYMPHATIC  CIRCULATION. 

Of  the  different  parts  which  compose  this  apparatus,  one  only  seemed  to  us 
to  be  a very  frequent  seat  of  lesion  — we  mean  the  mesenteric  ganglions. 
Every  time  we  found  the  intestine  exanthematous  or  ulcerated,  these  ganglions 
were  observed  to  be  seriously  changed.  They  were  much  larger  than  natural ; 
their  tissue  was  red  or  brownish  ; it  was  torn  under  the  finger  with  the  greatest 
ease  ; and  sometimes  small  purulent  deposits  were  scattered  through  one  or 
more  ganglions. 

The  mesenteric  ganglions,  which  appeared  to  us  most  constantly  and  most 
seriously  altered,  were  those  which  corresponded  to  the  portions  of  intestine 
most  diseased,  namely,  at  the  termination  of  the  small  intestine,  or  at  the 
caecum.  There  was  always  a direct  ratio  between  the  intensity  of  the  intestinal 
lesion  and  that  of  the  lesion  of  the  glands. 

In  some  individuals,  who  died  when  the  intestinal  lesion  was  now  proceeding 
towards  a cure,  or  was  already  cured,  there  still  remained  some  traces  of  the 
affection  of  the  mesenteric  ganglions ; they  were  still  increased  in  size  ; and 
their  violet  colour  indicated  in  these  bodies  a residue  of  inflammation  in  its 
decline. 

From  these  facts,  we  think  we  may  lay  it  down  that,  in  fevers,  the  affection 
of  the  mesenteric  ganglions  is  consecutive  on  the  intestinal  affection,  and  that 
it  is  a product  of  the  latter.  There  is  a resemblance  between  the  engorgement 
which  the  glands  of  the  mesentery  then  undergo,  and  that  which  the  lymphatic 
ganglions  of  the  axilla  or  groin  undergo,  when  a virus,  any  irritating  matter 
whatever,  comes  to  be  deposited  in  the  tissue  of  the  parts  whose  lymphatic 
vessels  terminate  in  these  glands.  It  has  been  said  that,  like  the  ganglions  of 
the  axilla  or  groin,  the  glands  of- the  mesentery  became  diseased  only  in  conse- 
quence of  the  absorption  of  the  irritating  matter  produced  on  the  surface  of  the 
ulcerated  mucous  membrane.  It  has  been  added,  that  the  mixture  of  this 
matter  with  the  lymph  and  blood  might  be  considered  as  the  cause  of  several  of 
the  symptoms  which  characterize  bad  fevers.  All  this  is  possible  ; but  observe 
that,  in  order  that  the  axillary  or  inguinal  glands  may  be  engorged,  it  is  not 
necessary  that  the  absorption  of  the  irritating  matter  should  have  taken  place  ; 
it  is  sufficient  that  any  point  whatever  of  the  skin  or  cellular  tissue,  from  which 
the  lymphatics  going  to  these  glands  arise,  should  be  pricked  or  irritated  in  any 
way.  The  case  may  be  the  same  for  the  mesenteric  glands.  But  why  does 
inflammation  of  these  invariably  follow  intestinal  irritation  ? Why  does  in- 
flammation of  the  glands  of  the  axilla  or  groin  much  less  frequently  follow 
irritation  applied  to  the  point  of  origin  of  the  lymphatics,  which  terminate  in 
these  ganglions  ? 


RESPIRATORY  APPARATUS. 


SECTION  I. 

LESIONS  OF  THIS  APPARATUS  OBSERVED  AFTER  DEATH. 

The  bronchi  presented  nothing  remarkable.  We  have  found  nothing  else 
in  them  but  more  or  less  redness,  similar  to  that  seen  in  a great  number  of 


DISEASES  OF  THE  ABDOMEN. 


177 

other  cases.  In  several  they  contained  a considerable  quantity  of  mucus,  some- 
times colourless,  sometimes  reddish. 

If  the  bronchi  presented  nothing  worth  remarking,  the  same  cannot  be  said 
of  the  parenchyma  of  the  lung.  We  found  this  structure  healthy  in  only  the 
smaller  number  of  our  cases.  In  these  latter  it  presented  at  most  that  slight 
engorgement  which  is  met  in  almost  all  dead  bodies.  But  in  many  cases  this 
engorgement  was  much  greater.  On  cutting  into  the  lung,  or  on  pressing  it 
between  the  fingers,  there  was  observed  to  ooze  from  it  a very  great  quantity 
of  a liquid  more  or  less  frothy,  sometimes  colourless,  but  most  frequently  red- 
dish. This  engorgement  was  so  great,  that  it  could  not  be  considered  as  a 
mere  cadaveric  effect.  It  was  probably  the  first  degree  of  pulmonary  inflam- 
mation. 

In  others,  instead  of  this  engorgement,  whether  serous  or  sero-sanguinolent, 
there  was  more  or  less  extensive  hepatisation  of  the  pulmonary  parenchyma. 
This  hepatisation  was  red  in  the  greater  number  of  cases,  and  in  some  cases  it 
was  grey,  or  mixed  with  commencing  purulent  infiltration.  (Cases  1,  5,  15, 
17,  22,  24,  26,  27.) 

On  one  occasion  we  observed  gangrene  of  the  lung  ; it  was  in  one  of  the  indi- 
viduals whose- lung  was  hepatised  ; but  the  hepatisation  existed  in  the  lower 
lobe,  and  the  gangrene  in  the  centre  of  the  upper.  This  gangrene  we  con- 
sidered merely  as  an  accidental  complication  of  the  disease. 

On  two  occasions  small  purulent  abscesses  were  scattered  through  the  pul- 
monary parenchyma;  but  these  were  cases  of  a peculiar  nature,  and  those  ab- 
scesses appeared  to  be  formed  consecutively  to  the  presence  of  pus  in  the  torrent 
of  the  circulation.  In  one  of  these  cases  there  had  been  phlebitis,  and  in  the 
other  the  principal  disease  was  confluent  small-pox.  In  three  cases  the  lung 
contained  tubercles. 

In  another  case  cancerous  masses  were  scattered  through  the  lung,  and  lym- 
phatic vessels,  full  of  matter  resembling  softened  cancer,  traversed  the  circum- 
ference of  the  lung,  and  entered  into  its  substance. 

Of  these  different  lesions  none  belongs  peculiarly  to  the  genus  of  diseases 
now  under  consideration.  The  following,  on  the  contrary,  though  having  been 
observed  in  several  other  diseases,  appeared  to  us  to  present  itself  more  parti- 
cularly in  bad  fevers.  In  this  lesion  the  pulmonary  parenchyma,  having  be- 
come impervious  to  the  air,  as  in  the  case  of  hepatisation,  presents  a brown  or 
livid  red  tissue,  which  is  under  the  finger  like  a sort  of  pulp.  In  this  state  the 
lung  very  much  resembles  certain  spleens  remarkable  for  their  great  softness. 
We  shall  be  able  to  form  an  idea  of  this  lesion  of  the  lung,  and  to  see  in  what 
states  of  disease  it  supervened,  by  referring  more  particularly  to  cases  6,  14, 
16,  21. 

Only  twice  we  found  in  the  pleura  albuminous  membraniform  concretions, 
traces  of  a recent  pleurisy. 

In  some  individuals  the  cavity  of  the  pleurae  was  filled  with  a red  liquid 
resembling  blood  just  taken  from  a vein.  In  one  of  these  cases  there  was  at 
least  a pint  in  each  pleura  ; in  another  case  the  pericardium  also  contained  some. 

M.  Louis  has  also  several  times  met  similar  effusions  in  persons  who  died 
of  the  disease  called  by  him  typhoid.  Neither  in  the  cases  which  he  reports, 
nor  in  ours,  did  the  pleura  present  any  thing  else  of  a morbid  nature  except  the 
effusion  itself. 

These  sanguineous  effusions  seem  to  us  so  much  the  more  deserving  of  being 
noticed,  as  they  have  been  often  found  in  the  bodies  of  animals  in  whom  the 
symptoms  of  adynamic  fever  had  been  produced  by  injecting  putrid  matter  into 
their  veins. 

From  this  recapitulation,  one  may  form  an  opinion  how  great  the  number  of 
patients  was  who  died  having  the  respiratory  passages  affected.  This  affection 


178 


ANDRAL’S,  MEDICAL  CLINIC. 


almost  always  coincided  with  that  of  other  parts,  and  particularly  of  the  diges- 
tive tube.  Sometimes,  however,  in  persons  who  died  with  the  symptoms  of 
what  is  called  adynamic  fever,  we  found  no  other  lesion  but  pneumonia  ; and 
in  this  case  it  seemed  to  us  that  the  commencement  and  origin  of  the  disease 
should  be  placed  in  the  pulmonary  lesion.  We  have  dwelt  so  long  on  this 
point  in  the  observations  we  made  on  our  particular  cases,  that  we  shall  not 
return  to  it  here.  Sometimes,  again,  the  pulmonary  affection  developed  itself 
during  convalescence,  and  occasioned  death. 


SECTION  II. 

LESIONS  OF  THE  RESPIRATORY  APPARATUS  OBSERVED  DURING  LIFE. 

The  functional  disturbances  of  this  apparatus,  in  continued  fevers,  do  not 
correspond  in  their  apparent  severity  with  the  intensity  and  frequency  of  the 
disturbances  which  anatomy  discovers  after  death.  In  this,  more  than  in  any 
other  disease,  the  most  serious  alterations  of  the  pulmonary  parenchyma  com- 
mence, and  become  developed  in  a manner  entirely  latent;  and  oftentimes  the 
disorganisation  of  the  lung  is  completed  before  even  we  could  have  suspected  it 
to  be  the  seat  of  any  lesion  whatever.  This  is  so  much  the  more  remarkable, 
as  it  is  here  in  an  acute  form  that  the  pulmonary  affection  is  developed.  We 
shall  now  pass  in  review  the  different  cases  which  have  fallen  under  our  obser- 
vation. 

At  the  onset  of  the  disease,  it  is  often  observed  that,  at  the  same  time  that  the 
symptoms  of  intestinal  irritation  become  developed,  other  symptoms  also  appear 
which  denote  the  existence,  of  an  active  hyperemia  of  the  mucous  membrane  of 
the  air  passages.  By  its  symptoms  the  seat  of  the  disease  seems  to  be  in  the 
gastro-pulmonary  mucous  membrane  ; oftentimes  even  the  signs  of  irritation 
of  the  bronchial  mucous  membrane  are  the  least  equivocal.  The  patients 
cough  ; they  expectorate  a transparent  mucus,  in  which  some  striae  of  blood  are 
occasionally  observed  ; they  complain  of  a painful  sensation  within  the  chest ; 
some  say  that  they  feel  a burning  or  tearing  all  along  the  sternum  ; others  com- 
plain of  pains  which  proceed  from  different  points  of  the  thoracic  parietes,  or 
are  confined  to  one  point  of  these  parietes  ; some  have  even  more  or  less  pain 
in  respiring,  and  they  evidently  labour  under  some  oppression. 

If,  with  such  a group  of  symptoms,  the  chest  be  percussed,  the  sonorousness 
of  its  parietes  is  most  frequently  found  to  have  undergone  no  change.  If  aus- 
cultation be  employed,  sometimes  nothing  unusual  is  discovered,  the  respiratory 
murmur  is  everywhere  pure  as  in  the  normal  state  ; it  is  sometimes  louder  ; 
and  as  we  have  stated  elsewhere,  there  is  then  reason  to  apprehend  that  some 
of  the  pulmonary  lobules  have  become  impervious  to  air.  Sometimes  different 
rales  are  heard,  which  indicate  either  the  existence  of  a certain  quantity  of  mucus 
in  the  bronchi,  or  a slight  engorgement  of  the  mucous  membrane  of  the  tubes. 

These  different  symptoms  often  exist  only  during  the  first  days  of  the  disease ; 
they  are  observed  to  disappear  either  spontaneously,  or  after  a bloodletting  ; 
and  sometimes  after  a vomit;  and  the  disease  then  seems  to  become  more  and 
more  concentrated  in  the  digestive  tube.  At  other  times  these  symptoms  con- 
tinue, without  becoming  worse,  during  the  entire  course  of  the  disease.  At 
other  times  they  become  worse  : the  irritation  of  the  pulmonary  mucous  mem- 
brane extends  to  the  parenchyma  of  the  organ,  and  all  the  signs  of  pneumonia 
appear. 

But  it  is  not  in  this  way  that  the  pneumonia  which  complicates  continued 
fever  most  usually  sets  in.  Frequently  it  supervenes  at  a period  much  more 
remote  from  their  outset,  and  in  persons  who,  till  then,  had  not  presented  any 


DISEASES  OF  THE  ABDOMEN. 


179 

trace  of  pulmonary  lesion,  either  in  the  rational  signs,  or  by  means  of  auscul- 
tation. 

Two  cases  may  then  present  themselves  ; in  one  the  pneumonia  is  announced 
by  its  characteristic  symptoms  ; in  the  other  it  remains  latent,  and  auscultation 
or  percussion  alone  can  detect  its  existence.  When  the  former  occurs,  the  pa- 
tients, after  having  had  some  shivering,  or  without  that  symptom,  are  seized  with 
cough,  stitches  in  the  side,  rust-coloured  sputa,  &c.  ; they  present  in  each  of 
these  symptoms  numerous  varieties  already  noticed  in  another  part  of  this  work, 
under  the  head  of  diseases  of  the  chest. 

The  second  case  may  present  itself  at  a period  when  the  patients  are  far  from 
having  fallen  into  the  adynamic  state  ; but  most  usually  the  pneumonia  remains 
completely  latent  only  when  it  attacks  an  individual  already  sunk  in  the  adyna- 
mic state,  or  in  whom  there  exist  different  nervous  symptoms,  more  or  less 
alarming.  It  is  principally  in  such  cases  that  instead  of  simple  engorgement, 
or  the  ordinary  red  or  grey  hepatisation,  we  find  the  brown  or  livid  softening, 
of  which  we  have  spoken  above. 

How  frequently  have  we  not  in  such  cases  found  a considerable  portion  of 
the  pulmonary  parenchyma  become  impervious  to  air  in  persons  who,  during 
life,  had  not  manifested  any  appreciable  difficulty  in  their  breathing,  who  had 
had  no  cough,  and  in  whom  the  sputa  were  either  altogether  ahsent,  or  merely 
mucous  ! It  is  then  of  the  utmost  importance  frequently  to  percuss  and  aus- 
cultate individuals  labouring  under  bad  fevers,  however  exempt  they  may  ap- 
pear to  be  from  any  affection  of  the  respiratory  apparatus. 

Without  being  indicated  by  any  of  its  ordinary  local  symptoms,  the  pneu- 
monia of  bad  fevers  may  produce  general  symptoms  of  a very  remarkable  kind. 
Thus  at  the  same  time  that  auscultation  apprises  us  of  its  invasion,  we  observe 
considerable  increase  in  the  prostration  of  the  patient ; suddenly  the  pulse  be- 
comes much  more  frequent,  and  often  extremely  feeble,  though  at  other  times 
it  acquires  some  hardness ; the  features  become  altered,  and  the  cheek  bones 
( pommettes ) present  a redness  which  forms  a striking  contrast  with  the  livid 
paleness  of  the  rest  of  the  face. 

The  pneumonia,  which  comes  on  during  convalescence,  is  most  usually  indi- 
cated by  symptoms  which  do  not  allow  us  to  mistake  it ; we  shall  not,  therefore, 
dwell  on  it  here.  But  we  shall  call  attention  fora  moment  to  another  case,  which 
we  have  sometimes  met.  Several  convalescents  complain  of  a cough  which,  at 
first,  seems  devoid  of  any  importance  ; still  this  cough  persists  ; the  fever  which 
had  entirely  disappeared,  reappears  under  another  form  ; every  evening  there  is 
an  acceleration  of  the  pulse,  and  some  heat  of  skin,  and  in  a little  time  this  febrile 
accession  is  terminated  every  morning  by  sweats.  The  strength  which  had  at 
first  appeared  to  return,  diminishes  more  and  more ; and  at  the  end  of  some 
time,  there  can  no  longer  be  any  doubt  of  the  existence  of  pulmonary  phthisis. 
On  going  back  to  the  previous  history  of  such  cases,  we  find  that  in  some  there 
had  been,  before  their  last  illness,  divers  symptoms  which  might  cause  one  to 
apprehend  the  development  of  tubercles  in  them.  But  in  others  nothing  of  this 
kind  had  existed,  and  it  is  for  the  first  time  during  their  convalescence  that  they 
present  some  symptoms  of  tuberculisation  of  the  lung. 

In  all  that  has  been  now  said,  we  have  spoken  of  the  affection  of  the  respira- 
tory apparatus  only  as  a complication  of  fever ; but  there  are  other  cases 
wherein  this  affection  appears  to  be  the  origin  of  it.  This  is  what  is  observed 
principally  in  old  persons  ; when  a pneumonia  attacks  them,  it  is  scarcely  indi- 
cated by  its  ordinary  symptoms,  when  at  times  the  tongue  becomes  dry  and  black 
the  intellect  is  disturbed  ; we  observe,  in  a word,  all  the  phenomena  which 
characterise  what  is  called  adynamic  fever;  then  the  sputa  may  be  suppressed, 
the  oppression  may  be  slight,  and  the  cough  inconsiderable.  Without  percus- 
sion and  auscultation,  the  pulmonary  affection  is  still  overlooked,  or  lost  sight 


180 


ANDRAL’S  MEDICAL  CLINIC. 


of;  and  it  is  only  by  post-mortem  examination  that  all  its  severity  can  be  appre- 
ciated. In  no  place  else  is  there  any  lesion  detected  ; and  it  then  seems  quite 
natural  to  refer  the  adynamic  symptoms  presented  by  the  individual  to  the  dis- 
ease of  the  lung. 

Whilst  in  a considerable  number  of  individuals,  labouring  under  bad  fevers,  no 
local  symptom  discloses  the  existence  of  the  most  intense  pulmonary  lesions, 
there  are  other  persons  in  whom  there  is  observed  a very  marked  disturbance  of 
the  respiration,  without  any  disease  of  the  lung  being  found  after  death.  Whilst 
this  organ  remains  perfectly  healthy  to  the  eye  of  the  anatomist,  the  breathing  is 
observed  to  be  hurried,  slow,  difficult  or  extremely  irregular;  thus  some  patients 
are  observed,  in  whom,  within  a short  space  of  time,  the  respiratory  movements 
present  alternately  extreme  frequency,  and  then  considerable  infrequency. 
These  different  modifications  of  the  respiration  are  obviously  the  result  of  the 
disturbance  of  the  innervation.  Why  should  not  disturbance  of  the  nervous 
centres  occasion  an  irregular  contraction  of  the  inspiratory  or  expiratory  mus- 
cles, just  as  it  occasions  the  most  unusual  movements  in  the  muscles  of  relative 
life? 


APPARATUS  OF  THE  SECRETIONS, 


SECTION  I. 

LESIONS  OF  THE  CELLULAR  TISSUE. 

This  tissue  is  but  seldom  found  altered.  The  few  lesions  which  we  have 
met  in  it  are  the  following  : — 

1st.  Effusions  of  blood.  Thus,  in  two  cases,  a perceptible  quantity  of  blood 
infiltrated  the  cellular  tissue  placed  between  the  fibres  of  the  recti  muscles  of 
the  abdomen. 

2dly.  Collections  of  pus.  Sometimes  they  were  formed  during  the  course 
of  the  disease,  and  seemed  to  have  but  little  influence  on  its  termination  ; some- 
times the  period  of  their  appearance  coincided  with  that  of  a general  improve- 
ment of  the  symptoms.  Another  time  numerous  abscesses  which  presented 
themselves  also  coincided  at  first  with  the  establishment  of  convalescence. 
But  one  of  these  abscesses  did  not  close,  and  there  came  from  it  a profuse  sup- 
puration which  occasioned  death. 

In  one  of  our  cases  of  small-pox,  complicated  with  typhoid  symptoms,  there 
were  abscesses  in  the  cellular  tissue  of  the  neck  ; they  seemed  to  be  meta- 
static, similar  to  those  which  were  scattered  through  the  lung  in  the  same 
individual. 

In  two  of  our  cases  the  inflammation  of  the.  cellular  tissue,  which  terminated 
in  simple  suppuration  in  one  case,  and  in  gangrene  in  the  other,  appeared  at 
the  commencement  of  the  disease,  and  maybe  considered  as  its  very  origin  ; at 
least,  on  opening  the  bodies,  nothing  was  found  but  this  phlegmon,  to  explain 
the  adynamic  fever. 

3dly.  Serous  infiltrations.  These  have  been  observed  in  some  convales- 
cents ; they  were  confined  to  the  parts  around  the  ankles,  and  disappeared  spon- 
taneously after  some  days. 

In  a woman,  whose  case  is  not  contained  in  this  work,  we  observed  during 
convalescence  from  a bad  fever,  considerable  serous  infiltration  in  all  the  left 
lower  extremity.  This  infiltration,  which  set  in  rapidly,  followed  the.  appear- 


DISEASES  OF  THE  ABDOMEN. 


181 


ance  of  extremely  acute  pains  seated  on  the  left  iliac  region.  These  pains  we 
combated  by  the  application  of  leeches;  they  lasted  for  eight  days,  and  then 
disappeared.  The  oedema  of  the  limb  disappeared  soon  after.  In  this  case  we 
could  only  form  conjectures  regarding  the  cause  of  these  pains,  and  the  oedema 
which  followed  them. 


SECTION  II. 

LESIONS  OF  THE  SEROUS  MEMBRANES. 

We  have  already  spoken  of  red  effusions  formed  of  blood,  found  occasionally 
in  the  pleura,  in  the  pericardium,  and  in  the  peritoneum.  They  exist  without 
the  tissue,  whence  the  blood  comes,  presenting  any  appreciable  alteration,  and 
it  would  be  only  by  an  hypothesis  that  one  could  refer  to  an  inflammatory  pro- 
cess those  sanguineous  effusions,  which  oftentimes  appear  to  be  much  less  con- 
nected with  any  lesion  of  that  part  of  the  system  where  they  occur,  than  with 
certain  conditions  of  the  blood.  Accordingly,  these  effusions  are  produced  in 
animals,  who  receive  into  their  veins  certain  putrid  substances  ; or  the  latter 
produced  such  an  alteration  in  the  blood  as  to  prevent  its  coagulation  after 
death  ; such  effusions  are  found  to  occur  in  scorbutic  individuals. 

Inflammation,  properly  so  called,  of  serous  membranes,  is  a very  rare  phe- 
nomenon in  fevers.  Thus,  in  these  affections,  the  pleura  is  found  much  less 
frequently  changed  than  the  lung  ; and  the  peritoneum,  though  in  almost  im- 
mediate contact  with  the  mucous  membrane,  which  is  nearly  always  very  seri- 
ously changed,  generally  remains  intact,  except  in  the  cases  wherein  one  of 
the  ulcers  of  the  intestine  happens  to  perforate  it.  The  result  of  this  is  one  or 
other  of  those  varieties  of  peritonitis  already  noticed. 


SECTION  III. 

LESIONS  OF  THE  BILIARY  APPARATUS. 

In  our  experience,  the  liver  was  almost  invariably  found  to  be  healthy.  In 
a few  cases  its  tissue  was  found  to  be  extremely  dense ; but  that  was  a lesion 
purely  accidental,  which  in  all  probability  had  no  connexion  with  the  disease  of 
which  the  patients  died.  On  one  occasion  the  liver  was  found  to  be  extremely 
pale.  In  no  case  did  we  observe  it  to  present  lesions  connected  with  those  of 
the  digestive  tube. 

In  these  different  cases  the  principal  alteration  resided  in  the  digestive  tube  ; 
but  we  met  another  case  wherein  the  typhoid  symptoms  did  not  coincide 
with  any  other  alteration  except  red  softening  of  the  liver.  In  the  morbid  state 
of  this  organ  the  original  cause  of  the  symptoms  appeared  to  lie  here. 

Neither  have  we  seen  that,  in  M.  Bouillaud’s  observations  on  fever,  the  liver 
presented  any  thing  remarkable,  except  in  one  case,  wherein  this  organ  con- 
tained several  abscesses.  It  was  in  an  individual  who,  after  having  presented 
for  several  days  a jaundice  tint  with  pains  towards  the  right  hypochondrium, 
diarrhoea,  red  tongue,  great  anxiety,  alternations  of  heat  and  cold,  meteorism, 
hiccup,  delirium  towards  the  termination,  etc.,  was  suddenly  seized  with  hema- 
temesis,  after  which  he  died. 

In  the  part  of  our  Clinique  dedicated  to  the  consideration  of  diseases  of  the 
liver,  we  shall  find  a case  of  abscess  of  this  organ,  announced  by  no  other  symp- 
toms than  a febrile  disturbance,  without  any  organ  appearing  to  be  the  seat  of 
any  especial  lesion. 

16 


182 


ANDRAL’S  MEDICAL  CLINIC. 


In  the  facts  recorded  by  M.  Louis,  we  find  no  abscess  of  the  liver,  neither  do 
we  find  any  instance  of  lesion  of  this  organ,  to  which  the  name  of  hepatitis  can 
be  given.  But  M.  Louis  states  that  he  met  in  several  individuals  affected  with 
typhoid  fever,  a very  particular  state  of  the  liver,  in  which  this  organ,  at  the 
same  time  that  it  contained  very  little  blood,  and  that  a section  of  it  was  ob- 
served to  be  dry,  had  become  so  friable,  that  the  slightest  pressure  with  the 
finger  was  sufficient  to  reduce  it  to  a pulp.  M.  Louis  assigns  no  symptom  to 
this  state,  of  the  nature  of  which  he  acknowledges  himself  ignorant ; he  states 
that  he  met  it  in  other  persons  besides  those  labouring  under  typhoid  fever,  less 
frequently,  however,  than  in  the  latter. 

We  observed  nothing  similar  in  the  cases  contained  in  this  part  of  the  work  ; 
but  it  is  possible  that  at  the  time  they  were  taken  this  lesion  may  have  escaped 
us.  Since  we  became  acquainted  with  the  researches  of  M.  Louis,  we  have 
endeavoured  to  ascertain  the  existence  of  softening  of  the  liver  in  typhoid  fever, 
and  we  have  not  observed  that  this  softening  was  more  frequent  in  this  disease 
than  in  others.  In  other  cases  we  found  a softening  similar  to  that  mentioned 
by  M.  Louis  ; it  was  observed  in  its  highest  degree  in  two  women  who  died  of 
puerperal  peritonitis,  with  purulent  depositions  in  the  body  of  the  uterus,  but 
without  any  trace  of  pus  in  the  veins. 

We  have  never  met  any  morbid  change  in  the  gall  bladder.  With  respect  to 
the  bile  we  have  often  seen  it  changed  in  its  quantity,  and  sometimes  in  its 
qualities. 

Thus,  in  a considerable  numberof  dead  bodies,  we  have  found  the  duodenum 
and  upper  portion  of  the  jejunum  and  ileum  filled  with  a great  quantity  of  bile  ; 
we  very  seldom  discovered  any  in  the  stomach.  Beneath  it  the  mucous  mem- 
brane presented  to  us  three  different  aspects  : it  sometimes  had  a yellow  tint, 
which  the  bile  had  given  to  it  since  death ; it  was  sometimes  of  a more  or  less 
intense  red,  whilst  on  some  occasions  it  was  perfectly  white. 

Nothing  was  more  variable  than  the  state  of  the  bile  contained  in  the  gall 
bladder ; and  of  the  different  appearances  which  it  presented  to  us,  none  was 
observed  to  us  more  frequent  in  continued  fevers  than  in  any  other  disease. 
Thus  it  oftentimes  had  a deep  black  tint,  a very  great  viscidity,  and  a syrupy 
consistence.  At  other  times,  on  the  contrary,  the  gall  bladder  contained  a clear 
and  almost  colourless  liquid  resembling  serum. 

On  one  occasion  we  found  in  the  gall  bladder  and  in  the  excretory  ducts  a 
liquid  not  at  all  resembling  bile : it  was  a sort  of  sanious  matter,  somewhat 
like  the  ichorous  discharge  of  certain  ulcers. 

We  only  once  met  a calculus  in  the  gall  bladder. 

If  we  now  enquire  what  functional  disturbance  the  liver  and  its  appendages 
presented  to  us  during  life,  we  shall  find  them  to  be  very  few.  We  never 
detected  any  pain  in  the  right  hypochondrium  which  we  could  consider  as  apper- 
taining to  the  liver.  The  bilious  vomiting  and  purging  appeared  to  us  to  be  con- 
nected rather  with  a morbid  state  of  the  digestive  passages  than  with  any  lesion 
of  the  liver.  We  have  opened  the  bodies  of  persons  who  died  at  that  state  of 
the  disease  when  the  different  symptoms  of  what  is  called  bilious  fever  existed  : 
the  liver  presented  nothing  remarkable,  neither  was  there  any  considerable  quan- 
tity of  bile  in  the  primae  vise. 

In  the  individual  in  whose  liver  M.  Bouillaud  found  abscesses,  the  skin  had 
presented  an  icteric  tint;  but  it  should  not  be  inferred  from  this  that  we  shall 
find  the  liver  appreciably  changed  in  all  individuals  who,  during  the  progress  of 
a bad  fever,  may  happen  to  present  a yellow  colour  of  the  skin.  Thus,  one  of 
the  circumstances  which  may  present  it,  without  our  finding  any  lesion  of  the 
liver  after  death,  is  the  presence  of  pus  in  the  venous  system  ; and  in  this  case 
it  seems  evident  that  this  yellow  tint  is  owing  not  to  bile,  but  to  a particular  alter- 


DISEASES  OF  THE  ABDOMEN. 


183 


ation  which  the  blood  has  undergone  in  the  capillaries,  in  consequence  of  its 
admixture  with  pus. 

But  jaundice  may  present  itself  as  one  of  the  phenomena  of  bad  fevers  with- 
out the  presence  of  pus  in  the  blood,  and  always  without  any  appreciable  alter- 
ation of  the  liver.  An  individual  died  in  the  Charite,  September  1828,  with  all 
the  symptoms  of  what  is  called  adynamic  fever.  During  the  two  last  days  of 
his  life,  the  entire  skin  assumed  a well-marked  icteric  colour.  On  opening  the 
body  no  particular  lesion  accounted  for  this  jaundice ; there  was  nothing  remark- 
able in  the  liver,  nor  in  its  excretory  ducts  ; in  the  intestine  the  ordinary  exan- 
theme  was  found  in  the  stage  of  ulceration. 

The  appearance  of  jaundice  in  bad  fevers  coincides  sometimes  with  profuse 
hemorrhages,  either  from  the  nasal  fossae,  or  the  mucous  membrane  of  the  sto- 
mach or  intestines  ; and  in  this  case  again  observation  has  shown  that  it  is  not 
to  an  alteration  of  the  liver,  appreciable  at  least  by  anatomy,  that  the  jaundice 
can  be  attributed.  Thus,  for  instance,  neither  the  liver  nor  bile  ducts  presented 
any  thing  particular  in  an  individual  whose  case  has  been  reported  by  Desmou- 
lins.* This  person,  who  fell  sick  at  Havre  on  coming  from  Martinique,  present- 
ed the  following  symptoms  : 

On  the  first  and  second  day,  he  had  intense  headach,  delirium, a nd  extreme 
restlessness,  so  that  it  became  necessary  to  employ  the  straight-waistcoat ; blind- 
ness at  intervals  ; hiccup  ; hemorrhage  from  the  nasal  fossae,  mouth  and  anus  ; 
ecchymosis  on  different  points  of  the  skin  ; his  perspiration  dyed  h!l  linen 
yellow. 

On  the  third  day  there  was  general  jaundice  ; black  vomiting  ; total  blindness  ; 
coma,  with  convulsions  of  the  extremities  and  face  ; carphology.  He  died  on 
the  fifth  day. 

The  same  black  pitchy  matter  was  found  in  the  digestive  tube,  as  had  been 
passed  during  life  both  by  vomiting  and  stool.  The  gastro-intestinal  mucous 
membrane  was  of  a brown  red  colour.  There  was  nothing  remarkable  either 
in  the  liver  or  its  appendages . The  skin  contained  a considerable  quantity  of 
blood,  and  poured  it  out  in  jets,  when  an  incision  was  made  into  it. 

Another  remarkable  circumstance  in  this  case,  and  one  probably  connected 
both  with  the  hemorrhages  from  the  mucous  membrane  and  with  the  jaundice, 
is,  that  the  body,  which  was  opened  whilst  still  warm,  five  or  six  hours  after 
death,  already  presented  well-marked  emphysema  of  the  sub-cutaneous  cellular 
tissue. 

Might  not  one  be  inclined  to  admit  that  in  these  different  cases  the  yellow 
colouring  of  the  skin  is  principally  owing  to  the  blood,  which,  at  the  same  time 
that  it  escapes  from  the  surface  of  the  mucous  membrane,  also  leaves  its  vessels 
on  the  surface  of  the  skin,  either  in  some  detached  points,  which  gives  rise  to 
partial  ecchymosis,  or  over  the  entire  surface,  which  occasions  general  ecchymo- 
sis, and  imparts  to  the  entire  cutaneous  envelope  a yellow  tinge  ? 


SECTION  IV. 

LESIONS  OP  THE  URINARY  PASSAGES. 

The  urinary  passages  are  more  rarely  found  the  seat  of  lesion  than  any  other 
organ  of  the  body.  In  two  or  three  cases  the  mucous  membrane  of  the  bladder 
appeared  to  us  to  be  very  much  injected.  We  have  found  it  white  in  more  than 
one  case,  where,  during  life,  there  had  been  retention  of  urine  and  long  continued 
distension  of  this  viscus. 

* Journal  Complementaire  des  Sciences  Medicales,  tom.  12. 


184 


ANDRAL’S  MEDICAL  CLINIC. 


In  two  cases  only  were  the  urinary  passages  the  seat  of  very  serious  lesion, 
which  appeared  to  us  to  have  acted  an  important  part  in  the  production  of  the 
symptoms. 

In  one  of  these  cases  one  of  the  kidneys  was  very  red  and  extremely  friable  ; 
there  was  pus  in  the  ureters,  and  the  vesical  mucous  membrane  was  intensely 
red  ; all  the  other  organs  were  found  healthy,  and  it  appeared  to  us  that  the  well- 
marked  adynamic  fever  which  had  taken  place,  might  be  considered  as  having 
had  its  origin  and  cause  in  the  affection  of  the  urinary  apparatus. 

In  the  other  case  the  prostate  was  the  seat  of  an  immense  abscess  ; and  here 
again  this  lesion  was  the  only  one  of  any  importance  detected  on  opening  the 
body;  The  urine  contained  in  the  bladder,  when  examined  after  death,  present- 
ed nothing  particular.  The  urine  passed  by  the  patients  during  life  was  not  exa- 
mined by  us  with  sufficient  care  to  enable  us  either  to  deny  or  confirm  what 
has  been  stated  by  authors  concerning  the  qualities  of  the  urine  in  the  different 
stages  of  fever. 


SECTION  Y. 

LESIONS  OF  THE  SALIVARY  GLANDS  AND  OF  THE  PANCREAS. 

The^naxillary  and  sublingual  glands  presented  nothing  particular  in  any  of 
our  cases.  Such,  however,  was  not  the  case  with  the  parotid  glands,  and  par- 
ticularly with  the  cellular  tissue  surrounding  these  glands. 

Five  times  only  have  we  observed  any  considerable  tumefaction  in  the  parotid 
region.  In  these  five  cases  this  tumefaction  occurred  in  individuals  who  had  had 
the  symptoms  of  ataxo-adynamic  fever  in  an  extreme  degree.  In  none  of  these 
eases  could  we  consider  the  parotid  engorgement  as  critical  ; it  appeared  to  us 
to  be  merely  an  accidental,  though  dangerous  complication  of  the  disease,  or  one 
which  retarded  convalescence  when  the  parotid  became^enlarged  only  at  this 
latter  period. 

Thus  in  one  of  these  cases  the  very  day  on  which  the  enlargement  of  the  pa- 
rotid appeared,  the  thirteenth  day  of  the  disease,  the  symptoms  became  worse: 
the  gland  increased  in  size  on  the  following  days,  and  each  day  also  the  symptoms 
became  exasperated. 

In  one  of  our  cases  the  parotid  gland  became  enlarged  on  the  nineteenth 
day,  and  attained  all  at  once  an  enormous  size.  The  patient  died  two  days 
after. 

In  another  case  we  could  not  determine  with  precision  the  time  when  the  en- 
largement appeared  ; the  tumefaction  was  but  slight.  After  having  remained 
stationary  for  three  days,  the  tumour  gradually  diminished,  and  disappeared 
without  having  exercised  any  influence  on  the  disease.  This  case  terminated 
fatally. 

In  another  case  the  parotid  became  prominent  towards  the  twentieth  day, 
when  the  patient  was  nearly  convalescent.  According  as  the  parotid  enlarged, 
the  fever  was  rekindled,  and  adynamic  symptoms  reappeared.  The  tumour 
declined  towards  the  tenth  day,  and  we  observed  the  bad  symptoms  again  dis- 
appear, according  as  the  tumour  tended  towards  resolution. 

In  another  case  also,  it  was  a little  time  before  the  establishment  of  convales- 
cence, one  of  the  parotids  became  swollen.  This  engorgement  was  treated 
like  any  other  inflammation:  leeches  were  applied  to  the  tumour,  and  it  was 
covered  with  emollient  poultices  ; it  lasted  for  seven  days,  and  terminated  in 
resolution.  Convalescence  was  not  perfectly  established  till  after  the  disappear- 
ance of  the  parotid  enlargement.  This  tumefaction  having  come  on  in  an  indi- 
vidual who  was  already  exhausted  by  a very  severe  disease  would,  in  all  pro- 
bability, have  terminated  fatally,  if,  instead  of  meeting  it  from  the  very  instant 


DISEASES  OF  THE  ABDOMEN. 


185 


of  its  appearance  by  the  active  treatment  usual  in  every  inflammation,  it  had 
been  allowed  to  suppurate,  for  fear  of  disturbing  what  has  been  called  a critical 
movement  of  nature. 

When  a parotid  tumour  terminates  in  suppuration,  it  is  necessary  to  give  exit 
at  an  early  period  by  a proper  incision  to  the  pus  which  has  formed  between 
the  granulations  of  the  gland ; for  this  pus,  by  spreading  to  the  neighbouring 
parts,  may  give  rise  to  serious  consequences.  On  two  occasions  we  saw  the 
cartilaginous  portion  of  the  meatus  auditorius  destroyed,  by  the  pus  being 
allowed  to  remain,  and  the  abscess  of  the  parotid  discharge  itself  through  the 
ear. 

The  pancreas,  which  so  closely  resembles  the  salivary  glands  in  its  texture, 
is  not  more  frequently  affected  in  fevers  than  in  other  diseases.  Once,  how- 
ever, we  found  it  more  injected  than  usual.  This  injection  was  principally 
seated  in  the  cellular  tissue  interposed  between  the  lobules  of  the  gland.  This 
slight  lesion  coincided  with  tumefaction  of  one  of  the  parotid  glands.  * 


ORGANS  OF  THE  LIFE  OF  RELATION. 


SECTION  I. 

LESIONS  OP  THOSE  ORGANS  OBSERVED  AFTER  DEATH. 

A. — Nervous  Centres. 

There  are  few  organs,  in  persons  affected  with  continued  fevers,  which  pre- 
sent more  functional  disturbances  than  the  nervous  centres  ; there  are  few,  how- 
ever, which,  after  death,  present  fewer  lesions  appreciable  by  dissection  ; and 
if  there  be  any  truth  clearly  established  to  our  satisfaction,  it  is  this  : that  in 
what  are  called  essential  fevers,  there  is  no  nervous  symptom  which  may  not 
present  itself  without  any  appreciable  alteration  in  the  brain  or  its  appendages. 

With  the  exception  of  six  individuals  (cases  9,  15,  23,  26,  27,  37),  all  those 
whose  bodies  we  opened  had  had  delirium,  or  other  well-marked  disturbances 
of  the  nervous  functions,  at  the  time  they  died,  and  in  almost  all  these  disturb- 
ances of  the  innervation  existed  for  a considerable  time.  The  following  is  the 
state  in  which  the  nervous  centres,  or  their  appendages,  were  found : — 

The  sinuses  and  venous  trunks  which  surround  the  encephalic  mass  were 
found  gorged  with  blood  in  only  a very  small  number  of  cases.  In  the  indi- 
viduals who  form  the  subject  of  these  cases  the  symptoms  of  what  is  called 
ataxic  fever  had  predominated. 

In  some  cases  the  membranes  presented  different  degrees  of  injection.  This 
injection  coincided  on  two  occasions  with  death,  which  was  preceded  by  great 
embarrassment  in  respiration,  and  in  these  two  cases  it  might  be  considered  as 
entirely  mechanical.  Most  frequently  it  existed  in  only  a slight  degree.  In 
one  case  it  was  very  considerable,  but  appeared  only  in  some  points.  In  all  it 
had  its  seat  almost  exclusively  in  the  sub-arachnoid  cellular  tissue  of  the  con- 
vexity of  the  cerebral  hemispheres.  In  one  of  the  individuals  whose  membranes 
were  injected,  the  arachnoid  of  the  convexity  of  the  hemispheres  was  unusually 
friable.  In  some  the  subarachnoid  cellular  tissue  was  infiltrated  with  a quan- 
tity of  limpid  serum,  but  this  quantity  was  never  considerable. 

In  some  others  we  also  found  a little  serum,  either  within  the  ventricles  (never 
16* 


186 


ANDltAL’S  MEDICAL  CLINIC. 


more  than  three  or  four  small  spoonsful  in  each,  and  most  frequently  scarcely 
one),  or  at  the  base  of  the  cranium. 

In  no  case  was  the  serum  which  we  found  in  the  sub-arachnoid  cellular  tissue, 
in  the  ventricles,  or  at  the  base  of  the  cranium,  in  sufficient  quantity  perceptibly 
to  raise  the  arachnoid,  separate  the  convolutions,  or  occupy  any  considerable 
portion  of  the  occipital  fossae.  Thus,  these  effusions  being  but  inconsiderable, 
though  still  deserving  of  notice,  do  not  appear  to  us  of  such  importance  as  to 
warrant  us  in  taking  them  into  consideration  for  the  purpose  of  explaining  the 
symptoms. 

The  consistence  of  the  brain  appeared  to  us  perceptibly  diminished  in  only 
one  case.  On  raising  the  arachnoid,  which  was  red  and  friable,  we  brought 
with  it  portions  of  the  substance  of  the  convolutions.  The  softening  was  con- 
fined, moreover,  to  the  most  superficial  layer  of  the  latter. 

There  was  also  general  softening  of  the  brain  in  the  individual  whose  case 
has  been  reported  by  M.  Gauthier,  and  of  which  we  have  spoken  in  the  remarks 
which  follow  our  forty-seventh  case.  But  in  that  case  this  softening  coincided 
with  diminished  consistence  in  several  of  the  other  tissues. 

We  have  found  perceptible  increase  in  the  consistence  of  the  brain  in  only 
one  case.  This  unusual  firmness  coincided  with  considerable  injection  of  the 
membranes.  Stupor  had  been  the  prevailing  phenomenon  during  life. 

Wheuever  the  nature  of  the  symptoms  induced  us  to  examine  the  spinal  cord, 
we  detected  nothing  remarkable  in  it. 

Such  are  the  rare,  and  for  the  most  part  very  slight  alterations,  which,  being 
found  in  the  brain,  might  be  considered  as  of  recent  formation. 

In  some  other  cases  we  met  more  serious  alterations  in  the  brain  or  around 
it,  but  such  as  had  no  connexion  with  the  disease  of  which  the  patient  died  ; 
thus  in  one  individual  there  was  an  old  apoplectic  clot  ( foyer );  in  another  a 
bony  granulation  was  implanted  in  a part  of  the  cerebral  substance.  In  a third 
a false  membrane  of  a fibrous  appearance  was  placed  between  the  arachnoid 
and  dura  mater  on  the  one  hand ; between  the  arachnoid  and  pia  mater  on  the 
ether. 

We  have  also  made  mention  of  some  individuals  in  whom  small  purulent 
depositions  were  scattered  through  the  encephalic  mass,  and  who  had  died  with 
typhoid  symptoms.  But  in  them  there  were  at  the  same  time  abscesses  in 
twenty  other  parts  of  the  system,  they  were  connected  either  with  phlebitis,  or 
purulent  absorption  ; this  was  the  cause  of  all  the  symptoms,  and  the  brain,  in 
such  cases,  presented  no  particular  functional  disturbance, 

Did  the  individuals  who  presented  the  different  states  of  the  brain  now  passed 
in  review,  present  any  thing  particular  in  the  symptoms?  by  no  means.  Ner- 
vous symptoms  of  the  same  nature,  of  the  same  intensity,  and  of  the  same  du- 
ration were  observed,  both  in  those  whose  brain  or  its  appendages  seemed  to 
present  something  no  longer  normal,  as  also  in  those  the  integrity  of  whose 
nervous  centres  had  undergone  no  species  of  appreciable  alteration. 

But,  further,  it  is  far  from  being  true  that  it  is  in  bad  fevers  only  that  we 
meet  engorgement  of  the  sinuses,  injection  of  the  membranes,  effusion  of  serum 
in  different  parts  of  the  cavity  of  the  arachnoid,  or  outside  this  cavity,  red  points 
in  the  cerebral  substance,  numerous  shades  in  its  consistence,  etc.  All  these 
states  we  have  also  met  in  many  other  cases  where,  during  life,  no  nervous 
disturbance  had  been  observed ; so  that  in  the  cases,  where  one  of  these  states 
coincided  with  some  disturbance  of  the  innervation,  we  may  reasonably  doubt 
whether  this  state  has  been  the  cause  of  the  functional  disturbance. 

The  nervous  centres  of  organic  life  were  examined  by  us  in  a considerable 
number  of  cases  ; twice  only  did  they  present  any  appearance  of  alteration  : it 
was  in  the  case  of  two  individuals  who  died  with  a group  of  well-marked  ady- 
namic symptoms ; the  semilunar  ganglions  were  remarkably  red.  One  of 


DISEASES  OF  THE  ABDOMEN. 


1S7 


these  individuals  had  experienced  during  the  last  forty-eight  hours  of  his  exist- 
ence violent  trismus  and  tetanic  rigidity  of  the  upper  extremities.  We  would 
not  venture  to  assert  that  in  these  cases  the  redness  of  the  semilunar  ganglions 
was  a morbid  state  ; for  repeated  researches  have  taught  us  that  these  ganglions 
are  very  variable  in  colour,  a circumstance  depending  on  the  kind  of  death 
and  the  quantity  of  blood  contained  in  the  different  capillaries. 

Thus  it  may  be  laid  down  that,  in  fevers  called  essential,  the  state  of  the 
nervous  centres  after  death  cannot  account  for  the  disturbances  which  they  pre- 
sented during  life.* 

Are  the  functional  disturbances  of  the  nervous  centres,  in  these  fevers,  the 
uniform  sympathetic  result  of  a morbid  state  of  the  stomach?  This  cannot  be 
admitted  ; for  in  the  majority  of  cases  we  have  found  no  constant  connexion 
between  the  state  of  the  stomach  and  the  lesion  of  the  nervous  functions  ; we 
have  already  stated,  that  this  organ  was  found  perfectly  healthy  after  death  in 
many  persons,  who  up  to  the  last  moments  of  life  had  had  nervous  symptoms 
of  the  most  serious  and  varied  description.  No  doubt,  however,  but  these 
symptoms  may  be  the  sympathetic  effect  of  a gastric  irritation  ; but  all  we  wish 
to  lay  down  here,  which  also  results  from  the  researches  of  M.  Louis,  is,  that 
this  irritation  is  not  necessarily  the  original  cause  of  the  nervous  disturbances 
which  come  on  in  bad  fevers,  and  even  that  in  most  cases  these  disturbances 
cannot  be  explained  by  the  state  in  which  the  stomach  is  found  after  death. 

May  we  refer  the  nervous  disturbances  in  bad  fevers  to  the  state  of  the  small 
intestine,  and  particularly  to  dothinenterite  ? Certainly  we  may  in  a great 
number  of  cases,  but  not  in  all.  In  several  of  these  cases,  where,  in  order  to 
account  for  the  very  severe  symptoms,  nothing  is  found  but  some  follicular 
patches  swollen,  or  slightly  ulcerated,  there  is  some  ground  for  hesitating  to 
refer  such  great  disturbance  to  such  slight  lesions  ; there  is  reason  for  thinking 
that  behind  these  visible  lesions,  and  before  their  appearance,  there  existed  in 
the  previous  state  of  the  patient  some  serious  derangement,  without  which  such 
alarming  symptoms  would  not  have  been  produced.  No,  the  intestinal  affec- 
tion is  not  the  entire  cause  in  all  such  cases,  and  in  order  to  account  for  every 
thing  which  coincides  with  it,  or  appears  after  it,  it  becomes  necessary  to  in- 
troduce other  elements,  which  pathological  anatomy  has  not  yet  discovered 
by  means  of  the  scalpel.  Here  then,  as  in  numberless  other  cases,  that  which 
we  perceive  is  but  a part  of  that  which  exists. 

And,  moreover,  has  not  our  experience  pointed  out  to  us  other  cases  where, 
in  the  absence  of  all  trace  of  dothinenterite,  these  same  nervous  symptoms  were 
observed  ? Has  it  not  shown  us  cases  where  these  same  symptoms  were  still 
found  in  the  absence  of  all  species  of  intestinal  lesion  appreciable  by  anatomy, 
but  with  lesions  of  other  organs  ? We  cannot  forget  those  uncommon,  but  yet 
real  cases,  in  which,  in  the  absence  of  any  organic  lesion  appreciable  after 
death,  the  same  nervous  symptoms  were  still  present.  Refer,  for  instance,  to 
the  individual  who  forms  the  subject  of  our  twenty-fifth  case : — When  con- 
valescent from  a dothinenterite,  a moral  excitement  acted  on  him ; he  all  at 
once  presented  symptoms  which  indicated  considerable  disturbance  of  innerva- 
tion. He  died  in  a few  days ; and  anatomy  discovered,  neither  in  the  nervous 
centres  nor  elsewhere,  any  lesion  to  account  for  the  alarming  phenomena  which 
hurried  him  to  the  grave. 


* This  opinion  is  further  confirmed  by  the  recent  observations  of  M.  Louis.  In  his  Traiie 
de  la  Fievre  Typhoide  (tom.  ii.  page  154),  this  gentleman  says : “ The  apparent  state  of  the 
brain  could  not  explain  the  symptoms  of  which  it  had  been  the  source,  just  as  the  state  of  the 
mucous  membrane  of  the  stomach  does  not  account  for  the  loss  of  appetite  and  other  gastric 
symptoms  in  a great  number  of  cases.” 


1S8 


ANDRAL’S  MEDICAL  CLINIC. 


B. — The  Muscles. 

It  has  been  frequently  staled,  that  the  muscles  of  individuals  labouring  under 
adynamic  fever  presented  to  the  touch  a pitchy  ( poisseux ) feel,  which  charac- 
terised diseases  of  this  kind.  We  feel  warranted  in  asserting  that,  in  a con- 
siderable number  of  cases,  we  did  not  discover  this  state  of  the  muscles  ; and 
that,  on  the  other  hand,  we  have  observed  it  on  the  bodies  of  persons  who  died 
of  different  acute  diseases. 

If  the  great  development  of  the  muscles  uniformly  indicated  the  amount  of 
vital  energy  possessed  by  each  individual,  we  could  net  believe  in  the  existence 
of  a real  adynamic  state  in  several  individuals  who  died  with  all  the  symptoms 
of  the  greatest  prostration.  In  such  cases  we  found  the  muscles  remarkable 
for  their  size,  their  firmness,  and  their  great  redness.  How  are  we  to  explain 
the  singular  softening  which  the  entire  muscular  system  presented  in  the  indi- 
vidual alluded  to  in  the  observations  following  our  forty-seventh  case  ? 


SECTION  II. 

LESIONS  OF  THE  ORGANS  OF  THE  LIFE  OF  RELATION  OBSERVED  DURING 

THE  DISEASE. 

A. — Lesions  of  the  Functions  of  the  Nervous  Centres. 

These  centres,  observed  at  the  different  stages  of  the  disease,  present  to  us 
disturbances  in  their  functions  as  frequent  as  the  lesions  which  they  present 
after  death  are  uncommon.  We  shall  recapitulate  whatever  these  functional 
disturbances  have  presented  most  remarkable  at  the  onset  of  the  disease,  or 
during  its  progress. 

At  its  onset  the  disease  may  assume  one  of  the  following  forms  : — 

First  Form.  — Apyretic  disturbance  of  the  digestive  functions  (anorexia  or 
diarrhoea),  without  the  appearance  of  any  functional  disturbance  of  the  nervous 
centres. 

Second  Form.  — Apyretic  disturbance  of  the  digestive  functions,  with  slight 
nervous  symptoms,  such  as  headach,  tinnitus  aurium,  swooning,  pains  in  the 
region  of  the  kidneys,  spontaneous  lassitude,  pains  in  the  limbs,  and  princi- 
pally towards  the  articulations,  a feeling  of  debility. 

Third  Form  — Febrile  disturbance  of  the  digestive  functions,  with  the  same 
nervous  symptoms. 

Fourth  Form.  — Absence  of  any  disturbance  of  the  digestive  functions,  or  at 
most  a diminution  of  appetite.  The  same  nervous  symptoms,  without  fever,  j 

One  or  other  of  these  symptoms  may  predominate  more  particularly. 

Thus,  in  a great  number  of  individuals,  there  is  observed  at  first  a pain  of  head, 
which  is  often  very  acute,  and  which  lasts  for  several  days  without  being  accom- 
panied by  any  other  symptom. 

In  others  the  commencement  is  particularly  marked  bylipothymia  anddazzling 
(eblouis  semens). 

Some  individuals  experience,  before  any  other  symptom,  pain  in  the  joints, 
which  sometimes  may  be  mistaken  for  a rheumatic  affection. 

Some  patients  feel,  in  the  first  instance,  a degree  of  debility  which  astonishes 
them,  without  having  any  fever,  and  without  their  appetite  being  much  dimi- 
nished. They  are  fatigued,  they  say,  after  walking  only  a few  steps ; every 
sort  of  exertion  is  painful  to  them  ; they  become  altogether  listless,  and  are  con- 
tent only  when  in  the  most  absolute  state  of  rest. 


DISEASES  OF  THE  ABDOMEN. 


189 


Fifth  Form.  — The  same  nervous  symptoms,  with  fever,  and  without  any 
apparent  disturbance  of  the  digestive  passages. 

Sixth  Form. — Severe  nervous  symptoms  from  the  very  onset,  such  as  delirium, 
stupor,  coma.* 

This  form  of  commencement  is  the  most  uncommon  of  all. 

If  we  now  trace  the  nervous  symptoms  in  the  course  of  the  disease,  we  shall 
find  them  sometimes  very  slight,  but  always  present ; sometimes  more  severe, 
and  then  constituting  bad  fevers.  For  every  fever  becomes  such  only  in  con- 
sequence of  the  part  which  the  nervous  system  takes  in  it ; and  by  no  means, 
and  this  cannot  be  too  often  repeated,  in  consequence  of  the  existence  of  such  or 
such  an  organic  lesion,  nor  of  an  affection  of  the  intestinal  follicles,  more  than 
of  any  other  organ.f 

We  have  carefully  studied,  in  our  several  cases,  the  infinitely  varying  forms 
of  the  disturbance  of  the  intellect.  Sometimes  this  disturbance  is  suddenly  car- 
ried to  an  extreme  degree  ; sometimes  it  is  established  only  gradually  ; the  pa- 
tients still  understand  every  thing  that  is  said  to  them,  and  answer  questions 
with  accuracy  ; but  lliey  have  a look  of  astonishment ; they  fiom  time  to  time 
pronounce  some  words  without  meaning,  or  they  can  scarcely  recollect  what 
happened  to  them  a few  minutes  before  ; others  make  short  and  abrupt  answers, 
and  sometimes  answer  slowly  and  vaguely  ; they  seem  to  endeavour  to  ascer- 
tain what  is  asked  of  them,  and  to  require  a great  effort  of  mind  to  answer  the 
most  simple  question.  After  a little  time  no  answers  are  returned,  unless  the 
question  be  repeated  several  times  ; and  ultimately  no  answer  whatever  can  be 

j 

* One  of  the  most  remarkable  cases  of  this  description  which  we  have  met  is  the  following : — 
A medical  student,  who  had  been  four  years  residing  in  Paris,  complained,  for  the  last  eight 
days,  of  slight  irritation  of  the  digestive  passages,  for  which  he  did  not  even  take  to  his  bed, 
when,  on  the  evening  of  the  24th  of  November,  1833,  he  was  suddenly  seized  with  violent 
delirium.  The  next  morning,  the  25th,  he  was  bled  to  the  extent  of  sixteen  ounces,  without 
any  improvement.  On  this  day,  at  two  o’clock  in  the  afternoon,  we  found  him  in  the  follow- 
ing state  : face  red,  eyes  sparkling,  great  agitation,  complete  delirium,  loud  cries.  The  patient 
springs  out  of  his  bed,  in  which  several  friends  of  his  were  not  able  to  keep  him.  It  became 
necessary  to  tie  him ; at  the  same  time  his  pulse  was  very  frequent  and  full,  skin  hot,  tongue 
red  and  gluey.  The  patient  was  immediately  removed  to  the  Pitid,  where,  by  my  directions, 
forty  leeches  were  applied  to  the  mastoid  processes.  They  abstracted  a considerable  quantity 
of  blood.  At  night  the  patient  fell  into  a state  of  great  debility,  and  all  his  body  was  covered 
with  a cold  perspiration.  However,  towards  midnight  his  strength  rallied  ; he  again  became 
very  restless,  and  rose  up  several  times,  and  wished  to  leave  his  bed.  On  the  morning  of  the 
25th  of  December,  he  was  more  calm,  but  the  delirium  still  continued;  cheeks  flushed,  whilst 
the  rest  of  the  face  was  of  a yellowish  tint ; tongue  dry  and  red  ; abdomen  slightly  tympa- 
nitic ; pulse  112.  I directed  a bladder  full  of  ice  to  be  applied  to  the  head,  and  the  lower  ex- 
tremities to  be  covered  with  sinapisms.  Whilst  the  ice  was  kept  to  the  head  the  patient  con- 
tinued very  calm ; he  then  fell  into  a sort  of  stupor  for  about  two  hours,  and,  when  come  out 
of  it,  he  had  his  reason  perfectly  restored.  On  the  following  morning,  the  27th,  his  intellects 
were  clear,  and  the  pulse  was  not  more  than  76.  At  night  a little  delirium  again  returned, 
with  some  fever ; the  ice  was  again  applied  to  the  head.  The  patient  asked  for  it  himself,  be- 
cause he  felt  that  it  calmed  him.  On  the  following  days  all  trace  of  delirium  disappeared  ; but 
the  febrile  disturbance  continued,  and  the  different  signs  which  characterise  dothinenterite  were 
observed.  They  ceased  gradually  ; and  the  patient  left  the  hospital  perfectly  recovered  on  the 
10th  of  January,  1834. 

f There  is  one  remark  to  be  made  here;  namely,  that  even  slight  irritations  of  the  digestive 
tube  react  more  readily  on  the  innervation  than  the  irritation  of  any  other  organ.  See,  for  in- 
stance, what  happens  to  a person  who  has  excited  his  stomach  by  either  too  much  food,  or  by 
food  of  too  stimulating  a nature  ; general  illness,  extraordinary  depression,  a feeling  of  debility 
and  fatigue,  of  pain  of  head,  or,  at  least,  a sense  of  weight  in  the  head,  total  unfitness  for  in- 
tellectual exertion  ; such  are  the  effects.  Certainly,  such  phenomena  are  observed  much  less 
frequently  under  the  influence  of  a bronchitis,  or  such  other  organic  irritation.  It  seems  to  be 
peculiar  to  gastro-intestinal  irritation  to  disturb  the  innervation  ; whilst  in  the  affections  of 
other  organs  there  is  required,  on  the  part  of  the  nervous  system,  a greater  predisposition,  in 
order  that  it  may  be  involved. 


190 


ANDRAL’S  MEDICAL  CLINIC. 


obtained.  Yet,  though  they  no  longer  answer,  they  oftentimes  still  comprehend 
what  is  said  to  them  ; they  give  the  arm,  or  put  out  the  tongue,  when  bid  to  do 
so.  In  this  state,  they  sometimes  observe  the  most  profound  silence,  their  in- 
tellect appear  gone,  or  else  the  expression  of  the  countenance  seems  to  indicate 
that  the  patient’s  mind  is  attentively  preoccupied  with  some  particular  thought. 
Sometimes,  instead  of  this  silence,  they  are  very  talkative  ; sometimes,  again, 
they  utter  loud  cries,  and  are  continually  vociferating.  Some  exhibit  a calm, 
indifferent  air ; others  manifest,  by  their  countenance,  the  expression  of  the  most 
intense  anxiety,  or  most  profound  despair.  They  become  very  much  discour- 
aged, and  consider  themselves  doomed  to  inevitable  death.  In  others,  on  the 
contrary,  the  first  indication  of  any  disturbance  of  the  intellect  is  the  persuasion 
which  they  feel  that  they  are  very  well,  that  they  are  becoming  better  and 
better,  according  as  their  disease  is  becoming  worse. 

This  delirium,  whatever  be  its  form,  is  oftentimes  continued  from  its  com- 
mencement. At  other  times  it  is  observed  to  be  only  transient ; at  other  times 
again,  it  returns  periodically  every  night. 

Instead  of  these  various  disturbances  of  the  intellect,  some  patients  present, 
from  an  early  period  of  the  disease,  a remarkable  tendency  to  sleep,  as  the  pre- 
vailing phenomenon ; as  soon  as  they  are  left  to  themselves,  they  close  their 
eyes,  and  seem  to  sleep  ; and  in  a little  time  they  can  be  no  longer  roused  from 
this  state  of  somnolence,  which  is  changed  more  or  less  rapidly  into  areal  coma. 
Sometimes  this  latter  symptom  is  continued  ; sometimes  it  alternates  with  a state 
of  exaltation,  during  which  the  patient  presents  one  of  the  varieties  of  delirium 
already  noticed. 

In  several  cases,  we  observe  extraordinary  and  rapid  alternations  of  coma, 
delirium,  and  perfect  clearness  of  intellect. 

B. — Lesions  of  Muscular  Action. 

Disturbance  of  muscular  action  often  accompanies  disturbance  of  the  intellect ; 
it  may  precede  it,  or  appear  simultaneously  with  it.  In  some  of  our  patients, 
we  have  observed,  before  there  was  any  trace  of  delirium,  or  somnolence,  the 
muscles  of  the  face  agitated  with  small  convulsive  movements,  principally  seated 
towards  one  or  other  of  the  commissures  of  the  lips.  In  others,  the  predominant 
phenomenon  was  a very  marked  tremor  of  the  extremities.  In  some,  subsultus 
tendinum  was,  as  it  were,  the  prelude  to  the  other  nervous  symptoms.  The  sub- 
ject of  case  twenty-five  presented,  at  the  period  of  his  relapse,  permanent  flexion 
of  the  fingers,  as  the  first  indication  of  the  disturbance  of  the  nervous  centres. 
In  one  of  our  cases  there  were  the  symptoms  of  catalepsy  ; in  case  twenty-eight, 
a well-marked  trismus  ; in  another  case,  tetanic  shocks  over  the  body  ; in  case 
twenty-nine,  a spasmodic  contraction  of  the  muscles  of  the  pharynx,  and  some  of 
the  symptoms  of  hydrophobia  : in  case  seven,  a modification  in  the  contractions  of 
the  diaphragm,  the  consequence  of  which  was  a very  distressing  hiccup,  which 
required  to  be  met  by  peculiar  treatment. 

Muscular  action,  instead  of  being  exalted,  appears  oftentimes  more  or  less 
completely  abolished.  Then  the  contractions  of  the  muscles  are  observed  to 
become  weaker  and  weaker,  and  also  extremely  uncertain  ; the  tongue,  as  it 
were,  trembles,  and  its  movements  seem  to  be  withdrawn  from  the  influence  of 
the  will.  At  a more  advanced  stage,  the  patients,  lying  on  their  back  perfectly 
motionless,  their  arms  fixed  along  the  trunk,  the  eye  extinct,  countenance  dull, 
intellect  in  a manner  gone,  skin  cold,  pulse  thready,  give  no  other  indications 
of  life  than  by  some  inspiratory  movements,  which  are  repeated  at  long  inter- 
vals. This  state,  which  resembles  the  last  struggle,  may,  however,  be  followed 
by  a return  to  health. 

In  more  than  one  case,  the  muscular  strength  seemed  completely  lost  ; and 


DISEASES  OF  THE  ABDOMEN. 


191 


where  it  appeared  that  motion  was  now  become  impossible,  we  have  seen  pa- 
tients exert  all  at  once,  in  the  midst  of  their  delirium,  a degree  of  energy  which 
we  could  not  have  suspected  them  capable  of ; these  same  patients,  who,  a few 
minutes  before,  fell  back  as  inert  masses,  when  an  effort  was  made  to  raise 
them,  suddenly  sat  up,  arose,  left  their  bed,  and  walked  about.  Others,  who, 
during  the  day,  appeared  to  be  sunk  in  the  last  degree  of  prostration,  uttered, 
however,  the  most  violent  cries  during  the  night,  and  required  to  be  tied,  in 
order  to  confine  them  to  the  bed. 

In  these  different  cases  the  term  debility , as  well  as  the  term  excitement , 
should  be  employed  with  considerable  reserve ; for  neither  of  them  faithfully 
represents  that  which  exists ; and  as  the  greater  number  of  the  organic  lesions 
observed  can  no  more  be  explained  by  excess,  than  by  deficiency  of  the  normal 
excitement,  in  the  same  manner  we  must  not  have  recourse  either  to  strength 
or  debility  for  the  purpose  of  explaining  the  great  modifications  of  the  innerva- 
tion, which  are  the  most  prominent  phenomena  of  bad  fevers,  and  are,  as  it 
were,  their  symptomatic  character.  By  eternally  adhering  to  this  dichotomy, 
and  taking  alternately,  as  the  expression  of  truth,  sometimes  the  former  and 
sometimes  the  latter  of  these  terms,  persons  have  certainly  gone  beyond  that 
which  was  supported  by  facts,  not  seeing  that  the  sthenic  as  well  as  the  asthenic 
state  was  equally  based  on  hypothesis,  and  that  it  would  have  been  wiser  and 
more  profitable  for  science  as  well  as  for  humanity,  to  recognise  in  these  great 
disturbances  of  functions  a state  of  modification,  or  of  perversion  of  the  nervous 
power,  which  therapeutics  should  no  more  attempt  to  meet  by  tonics,  than  by 
debilitants ; their  only  end  should  be  to  produce  in  the  system  a series  of  or- 
ganic movements,  which  may  have  the  effect  (an  effect,  by  the  way,  never  cer- 
tain, but  still  possible)  of  bringing  back  the  nervous  functions  to  their  normal 
state. 

Was  there  excess  of  strength,  or  excess  of  debility,  in  those  remarkable  cases 
of  sudden  death,  which  occurred  in  several  of  our  patients  at  a time  when  no 
serious  symptoms  had  as  yet  appeared  (cases  6,  8,  11,  23,  31)  ? Who  does 
not  see  that  the  dichotomy  of  Brown,  as  also  the  theory  of  Broussais,  are  alto- 
gether insufficient  to  account  for  the  phenomenon  ? Who  does  not  see  that  in 
this,  as  well  as  in  many  other  modifications  of  the  innervation,  there  is  some- 
thing else  besides  this  sthenic  and  asthenic  state,  to  which  it  would  be  more 
convenient  to  refer  every  thing  ? 

C. — Lesions  of  the  Functions  of  the  Organs  of  the  Senses. 

A considerable  number  of  our  patients  evinced  great  diminution  in  the  faculty 
of  hearing.  This  sometimes  manifested  itself  only  at  a very  advanced  period  of 
the  disease ; sometimes  it  preceded  the  ataxo-adynamic  symptoms,  and  led  us 
to  predict  their  development.  This  second  case  is  far  from  being  uncommon  : 
under  such  circumstances,  the  countenance  ordinarily  assumes  a peculiar  ex- 
pression of  stupor.  On  one  occasion  the  ajr  of  stupor  disappeared  all  at  once, 
at  the  time  when  the  ataxo-adynamic  symptoms  had  attained  their  maximum 
of  intensity. 

The  sense  of  vision  has  also  undergone  some  modifications.  It  was  alto- 
gether lost  in  some  instances  ; in  others,  fantastical  objects  presented  themselves 
to  the  patients.  The  pupils  were  oftentimes  observed  to  be  either  very  much 
contracted  or  dilated,  either  on  both  sides  at  once,  or  only  on  one  side.  The 
globe  of  the  eye  was  occasionally  observed  to  deviate  from  its  axis,  sometimes 
towards  the  inner,  sometimes  to  the  outer  side. 

In  such  of  these  cases  as  terminated  fatally,  we  detected  no  lesion  of  the 
nervous  centres,  which  could  account  for  those  different  modifications  of  the 
senses  of  hearing  and  vision. 

The  sense  of  smell  presented  nothing  particular.  But  the  mucous  membrane 


192 


ANDRAL’S  MEDICAL  CLINIC. 


in  which  this  sense  resides,  has  often  been  the  seat  of  a hemorrhage  which,  by 
its  frequency  and  connexions  with  other  symptoms,  merits  some  consideration. 
There  is  no  disease  in  which  attacks  of  epistaxis  has  been  so  frequently  ob- 
served. Epistaxis  occurs  at  three  different  stages  of  bad  fevers;  first,  at  their 
onset;  secondly,  during  their  progress  ; thirdly,  towards  their  termination. 

At  the  onset  the  epistaxis  is  often  connected  with  headach  and  all  the  signs  of 
cerebral  congestion  ; at  other  times  it  comes  on  without  these  signs  existing. 

During  the  progress  of  the  disease  it  coincides  in  some  individuals  with  intense 
redness  of  the  face,  injection  of  the  eyes,  dizziness,  a full,  rebounding  pulse,  and 
with  that  group  of  symptoms  which  constitute  inflammatory  fever.  But  in  other 
cases  such  is  not  the  case  ; it  is  observed  to  occur  at  the  time  when  the  signs 
of  the  adynamic  state  are  setting  in  ; oftentimes,  too,  it  is  the  precursor  of  them, 
and  according  as  it  is  repeated,  the  prostration  goes  on  increasing,  as  also  the 
paleness  of  the  face,  the  stupor,  disturbance  of  the  intellect,  subsultus  tendinum, 
etc.  More  than  once  have  we  seen  it,  in  such  circumstances,  manifest  itself 
after  copious  bloodletting,  and  return  again  according  as  the  latter  operation 
was  repeated.  We  have  also  observed  it  to  coincide  with  other  hemorrhages 
from  mucous  membranes,  or  with  the  development  of  more  or  less  petechias. 
In  several  of  these  cases  the  occurrence  of  one  or  more  attacks  of  epistaxis  ap- 
peared to  us  to  mark  very  distinctly  the  transition  of  a continued  fever,  which 
till  then  was  rather  mild  (bilious  or  inflammatory),  to  a much  more  alarming 
form  (ataxic  or  adynamic). 

Again,  in  some  instances,  epistaxis  was  accompanied  with  a visible  improve- 
ment in  the  symptoms  ; it  is  in  such  cases  that  it  has  been  considered  critical. 
In  one  of  our  cases,  the  nasal  hemorrhage,  whose  appearance  had  coincided 
with  a visible  amendment  in  the  disease,  afterwards  threatened  to  prove  fatal 
by  its  great  profusion.  It  ceased  on  the  employment  of  tonics. 

There  are  some  of  these  cases  of  epistaxis  whose  profuseness  increases  in 
the  direct  ratio  of  the  debility  of  the  patients  and  of  their  state  of  anaemia. 
Thus  it  is  often  very  difficult  to  arrest  the  blood  from  leech  bites  in  persons  of 
a lymphatic  constitution,  who  are  feeble,  and  exhausted  by  a lingering  disease, 
or  who  have  been  already  frequently  bled. 

Some  individuals  have  but  one  attack  of  epistaxis ; in  others  it  is  renewed, 
either  several  days  successively,  or  at  different  periods  ; and  if  in  certain  cases 
efforts  have  been  made  to  encourage  it,  in  other  cases  we  have  been  obliged  to 
have  recourse  to  mechanical  means  in  order  to  arrest  it  with  all  possible 
promptitude. 

As  the  sense  of  touch,  the  skin  has  presented  to  us  remarkable  anomalies  in  its 
sensibility.  This  sensibility  has  been  observed  to  be  destroyed  in  some  indi- 
viduals ; it  was,  on  the  contrary,  very  much  exalted  in  other  instances;  the 
sensibility  of  the  entire  skin  was  such,  that  the  slightest  pressure  made  on  any 
one  point  of  it  obliged  the  patient  to  scream.  Such  an  exaltation  of  the  sensi- 
bility, if  confined  to  the  skin  of  the  abdominal  parietes,  would  have  induced  one 
to  believe  in  the  presence  of  peritonitis.  Thus,  every  time  that  an  individual, 
labouring  under  a bad  fever,  appears  to  suffer  acutely  by  pressing  on  the  abdo- 
men, we  never  fail  to  press  other  points  of  the  skin  for  the  purpose  of  com- 
parison, the  better  to  ascertain  the  real  nature  of  the  abdominal  pain.  In  the 
subject  of  one  of  our  cases  the  cutaneous  sensibility  presented  in  a short  space 
of  time  rapid  alternations  of  diminution  and  exaltation. 

But  it  was  not  merely  as  a sense  of  touch  that  the  skin  has  been  found 
altered  in  some  of  our  cases.  First,  it  presented  to  us  different  modifications 
in  its  temperature,  which  we  have  already  noticed. 

The  exaltation,  of  which  it  is  the  seat,  has  seldom  remained  in  its  normal 
state.  In  some  it  was  increased  during  the  entire  course  of  the  disease,  and  in 
these  the  affection  was  generally  rather  mild.  The  state  of  moisture  or  per- 


DISEASES  OF  THE  ABDOMEN. 


193 


spiration  which  results  from  it  maybe  continued,  or  alternate  with  such  a state 
of  dryness  of  the  skin,  either  at  irregular  intervals,  or  periodically.  This 
periodical  return  of  the  perspiration  may,  or  may  not,  be  preceded  by  shivering. 

In  other  cases  the  cutaneous  transpiration,  far  from  being  increased,  has  ap- 
peared to  diminish,  or  to  be  suspended  altogether,  and  thence  that  peculiar  dry- 
ness of  the  skin  so  frequently  observed  in  our  cases,  and  which  is  always  con- 
nected with  a more  or  less  dangerous  state.  Does  not  this  dryness  of  the  skin 
also,  which,  in  no  disease,  is  so  marked  as  in  that  now  under  consideration, 
depend  on  the  suppression  of  the  follicular  secretion?  Be  this  as  it  may,  we 
have  never  seen  a decided  amendment  take  place,  until  the  skin  had  recovered 
the  softness  and  polish  which  it  presents  in  the  state  of  health. 

Several  individuals,  whose  skin  had  remained  constantly  dry,  began  to  per- 
spire at  the  same  time  that  their  state  became  improved,  and  every  thing  indi- 
cated in  them  a tendency  to  a favourable  termination.  In  twelve  of  our  patients 
in  particular,  we  observed  so  sudden  and  unexpected  an  improvement  in  all  the 
symptoms,  at  the  same  time  that  a perspiration  took  place,  that  we  were  inclined 
to  consider  it  as  critical. 

Most  frequently  we  have  been  unable  to  determine  with  accuracy  the  precise 
day  when  ihe  apparently  critical  perspiration  occurred.  However,  we  thought 
that  it  occurred  in  one  case  on  the  seventh  day,  in  another  case  on  the  twelfth, 
in  one  or  two  others  on  the  twenty-first.  In  one  case  the  sweats  occurred  at 
three  different  periods  ; on  the  seventh,  the  fourteenth,  and  eighteenth  day. 
The  last  only  coincided  with  any  improvement  in  the  disease. 

In  several  cases  these  -sweats,  which  were  immediately  followed  by  any 
amendment,  seemed  to  have  been  occasioned  by  emetics. 

However,  it  must  be  observed  that  the  appearance  of  the  perspiration  has 
been  far  from  being  invariably  followed  by  an  improvement  in  the  disease. 
Thus,  in  one  case,  when  it  first  appeared,  the  symptoms  were  observed  to  be- 
come worse,  and  yet  this  sweat  took  place  on  the  fourteenth  day.  In  some  the 
skin  became,  and  that  for  the  first  time  too,  the  seat  of  a profuse  sweat,  a few 
hours  before  death.  Often  also,  during  the  last  twenty-four  hours  of  life,  the 
skin  was  observed  to  be  covered  with  a clammy,  cold  sweat.  The  appearance 
of  this  sort  of  sweat  invariably  seemed  to  us  a most  unfavourable  sign. 

Some  persons  had  profuse  sweats  during  convalescence,  which  ceased  spon- 
taneously according  as  their  strength  returned. 

The  perspiration  of  persons  labouring  under  bad  fevers,  with  considerable 
prostration  and  leaden  tinge  of  the  face,  appeared  to  us  remarkably  fetid.  But 
this  phenomenon  is  far  from  being  as  frequent  as  has  been  stated  ; and  we  do 
not  think  that  any  thing  can  be  inferred  from  it  with  respect  to  the  nature  of 
the  disease.  We  do  not  see,  for  instance,  what  connexion  exists  between  the 
fetid  odour  of  the  sweat  and  the  putridity  of  the  humours,  which  some  have 
wished  to  prove  by  the  existence  of  this  peculiar  fetor  of  the  product  of  the 
cutaneous  transpiration. 

In  a great  number  of  cases  the  skin  was  covered  with  various  eruptions  — 
petechiae,  vibices,  sudamina,  miliary  pustules,  purple  eruption,  varioloid  pus- 
tules. Such  were  the  different  exanthemes  observed  by  us. 

Petechiae.  — The  petechial  eruption  appeared  in  a great  number. 

The  petechiae,  considered  with  respect  to  their  situation,  also  called,  from 
their  appearance,  lenticular  rose-coloured  spots,  most  frequently  appeared  on 
the  middle  and  lower  part  of  the  chest,  and  on  the  upper  part  of  the  abdomen. 
In  some  cases  they  covered,  at  one  and  the  same  time,  the  entire  surface  of  the 
chest  and  abdomen.  Twice  we  saw  them  extend  to  the  upper  extremities, 
once  to  the  thighs,  and  once  to  the  neck.  We  never  saw  them  on  the  face. 

Their  number  has  been  very  variable.  Several  patients  have  presented  but 
seven  or  eight  petechiae  at  most,  which  were  scattered  over  the  chest  or  epigas- 


194 


ANDllAL’S  MEDICAL  CLINIC. 


trium.  In  others,  the  eruption,  which  was  very  confluent,  covered  the  chest, 
abdomen,  neck,  arms,  and  thighs.  The  severity  of  the  accompanying  symp- 
toms was  not  always  proportioned  to  the  number  of  the  petechiae. 

The  breadth  of  these  spots  seemed  to  us  to  vary  from  that  of  a very  small 
fleabite  to  that  of  a lentil.  They  were  in  general  round,  but  sometimes  pre- 
sented an  oval  or  oblong  form.  On  passing  the  finger  slightly  over  these  spots, 
it  was  found  that  they  projected  a little  above  the  level  of  the  skin.  This  pro- 
jection, however,  was  not  perceivable  by  the  sight. 

The  colour  of  the  petechia?  presented  several  shades.  They  had  in  general 
a rather  bright  rose-coloured  tinge,  when  they  appeared  at  a period  when  the 
adynamic  symptoms  were  not  yet  much  marked.  But  in  almost  all  the  cases 
where  there  was  great  prostration,  and  great  stupor,  the  spots  were  pale,  or 
else  a livid  or  brown  colour  replaced  their  rose-coloured  tinge.  Quarin  rightly 
distinguished  three  species  of  petechiae  with  respect  to  their  colour  ; some  being 
red,  others  livid,  and  the  third  blackish.  These  last , he  said,  are  the  most  un- 
common and  the  most  unfavourable  ; those  that  are  of  a livid  colour  are  also 
very  alarming  ; nor  are  those  that  are  red  exempt  from  danger. 

We  have  not  been  able  to  ascertain  any  thing  definite  with  respect  to  the 
period  of  the  disease  at  which  the  petechiae  began  to  appear.  We  have  most 
frequently  seen  them  appear  in  the  middle  of  the  fever,  sometimes  towards  the 
end,  and  even  during  convalescence ; very  seldom  from  the  very  commence- 
ment. 

From  the  moment  when  each  spot  appears  ordinarily  to  have  attained  its 
greatest  development,  it  continues  five  or  six  days,  then  fades  and  disappears, 
without  leaving  behind  it  any  trace  of  its  existence. 

On  one  occasion,  however,  in  an  individual  who  had  had  a great  number  of 
petechiae,  we  observed,  after  their  disappearance,  a real  desquamation  of  the 
cuticle. 

In  general,  the  petechial  eruption  continues  discrete ; it  may,  however,  be- 
come confluent,  and  then  it  presents  in  its  appearance  some  resemblance  to  the 
eruption  of  measles.  In  some  cases  we  have  seen  the  petechiae  appear  and 
disappear  several  times  in  the  course  of  one  and  the  same  disease. 

Let  us  now  endeavour  to  ascertain  the  importance  of  the  petechiae  in  fever. 

Quarin  has  stated,  that  petechiae  are  common  in  putrid  fever,  less  frequent  in 
malignant  fever,  and  very  rare  in  inflammatory  fever.  Dehaen  repeats,  in 
several  of  his  works,  that  stupor  and  prostration  do  not  necessarily  accompany 
the  development  of  petechiae.  lie  has  seen  the  spots  come  on  during  the  pro- 
gress of  the  slightest  fevers.  Stoll  has  made  the  same  remark.  Likewise, 
with  respect  to  treatment,  these  authors  recommend  us  to  be  guided  chiefly  by 
the  aggregate  of  the  other  symptoms. 

Our  experience  entirely  confirms  the  preceding  statements.  We  have  seen 
petechial  spots  appear  during  the  course  of  the  mildest  fevers,  without  any  ex- 
asperation of  the  symptoms  following  their  appearance. 

These  slight  fevers,  with  petechial  eruption,  presented  themselves  under 
somewhat  of  an  epidemic  form.  They  began  to  appear  towards  the  end  of  May  ; 
they  became  very  numerous  during  the  months  of  June  and  July  ; they  then 
became  somewhat  diminished  in  August,  and  disappeared  in  September.  In 
all  these  cases  the  eruption  was  discrete,  and  presented  a rose-coloured  tinge. 

But,  as  had  been  well  remarked  by  Hoffmann,  Mead,*  and  Quarin,  should 
the  petechiae  be  numerous,  or  of  a bad  colour,  they  are  an  unfavourable  sign, 
and  accompany  an  adynamic  state  more  or  less  alarming.  Of  this  we  may 
satisfy  ourselves  by  referring  to  several  of  our  cases.  In  some  of  them  we  see 

* Quo  plures  numero  comparent,  eo  gravior  subest  metus.  Maximum  autem  vitae  periculum 
ostendunt,  cum  nigrae  vel  lividae  evadunt. 


DISEASES  OF  THE  ABDOMEN. 


195 


that  it  was  a little  time  after  bloodletting  had  been  employed,  or  after  profuse 
epistaxis,  that  the  spots  appeared  together  with  the  stupor. 

In  another  case,  on  the  contrary,  the  petechiae  and  stupor  disappeared  after 
the  application  of  leeches  to  the  anus.  On  the  day  after,  the  eruption  again 
appeared,  without  being  accompanied  by  more  severe  adynamic  symptoms. 

In  other  patients  the  petechiae,  after  having  appeared  during  the  worst  stage 
of  the  disease,  survived  in  a manner  all  the  other  symptoms,  and  a few  of  them 
still  continued  during  convalescence. 

At  other  times  we  have  seen  the  petechiae  fade  and  disappear  on  a sudden  at 
the  moment  when  the  adynamic  state  became  most  decided. 

In  one  case  the  petechiae,  after  having  increased  in  number  according  as  the 
stupor  increased,  almost  entirely  disappeared  the  day  before  death.  In  another 
patient  their  increase  in  number  and  in  the  brownness  of  their  colour  marked 
the  progress  of  the  adynamic  state.  They  disappeared  all  at  once  at  the  same 
time  that  the  nervous  symptoms  preceding  death  manifested  themselves.* 

Huxham  and  Ramazzini  have  spoken  of  critical  petechiae.  Pringle  and 
Sarcone  deny  their  existence.  In  only  one  case  Sarcone  saw  the  petechiae 
disappear  at  the  same  time  that  the  other  symptoms  of  the  disease  increased  in 
severity,  and  reappear  according  as  these  symptoms  became  more  mild.  For 
our  own  part  we  have  seen  on  two  occasions  the  appearance  of  the  petechiae  to 
coincide  with  a perceptible  diminution  of  the  symptoms. 

Beside  the  petechiae,  those  broad  livid  spots,  or  vibices , may  be  naturally 
placed  which  existed  in  Case  14,  and  which  seem  to  be  but  a variety  of  the 
petechial  eruption.  They  continued  for  only  twenty-four  hours.  It  was  this 
same  patient  whose  blood  presented  a sanious  appearance.  This  case  is  not 
devoid  of  interest. 

In  some  of  our  patients  we  observed  an  eruption  of  sudamina  ; this  eruption 
occurred  particularly  over  the  abdomen.  On  gentiy  passing  the  extremities  of 
the  fingers  over  the  skin  of  this  part,  a number  of  small  inequalities  were  felt, 
which  gave  it  a rough  appearance.  These  inequalities  consisted  of  a crowd  of 
miliary  vesicles,  as  it  were  crystalline,  with  parietes  perfectly  transparent,  and 
containing  a little  limpid  serum.  The  slightest  handling  destroyed  them.  After 
having  continued  for  one,  two,  or  three  days  at  most,  these  vesicles  disappeared, 
and  in  the  place  which  they  had  occupied  there  was  observed  a desquamation 
of  the  cuticle. 

In  one  case  only  the  sudamma  became  much  more  developed.  Several  of 
them  were  seen  to  combine,  and  form  large  vesicles.  One  would  say  that  it 
was  pemphygus.  It  was  in  this  individual  that  the  remarkable  eruption  of 
sudamina  appeared  at  one  and  the  same  time  over  the  abdomen,  thorax,  neck, 
and  arms,  but  principally  around  the  axillae. 

In  this  patient  and  in  four  others  profuse  sweats  preceded  or  accompanied 
the  eruption  ; but  as  sweating  equally  profuse  is  observed  in  many  persons 
who  exhibit  no  sudamina , it  is  reasonable  to  suppose  that  the  sudamina  cannot 
occur  without  a special  physiological  or  pathological  disposition  of  the  skin. 
Besides,  in  two  other  cases  no  remarkable  sweat  took  place.  In  the  subject  of 
Case  49,  the  appearance  of  the  sudamina  coincided  with  a perceptible  improve- 

* The  following  fact  told  me  by  M.  Senn,  house  pupil  at  the  Hotel,  seems  calculated  to 
prove  that  the  petechias  must  be  considered  as  the  result  of  general  debility.  A man,  under 
the  care  of  M.  Dupuytren,  was  seized  with  profuse  epistaxis,  which  could  not  be  arrested. 
After  some  time  it  was  no  longer  natural  blood,  but  only  a sort  of  serous  liquid  that  flowed 
through  the  nostrils.  The  patient  was  threatened  with  dying  of  exhaustion.  In  the  midst  of 
this  state  of  anemia,  numerous  petechiae  appeared  on  the  trunk  and  extremities ; the  epistaxis 
ceased,  and  according  as  the  strength  returned,  the  petechiae  faded.  Like  hemorrhages,  pete- 
cbiae  may  then  be  divided  into  active  and  passive. 


196 


ANDRAL’S  MEDICAL  CLINIC. 


inent  in  the  symptoms.  Five  times  this  eruption  appeared  in  summer,  and 
twice  in  October  and  February. 

In  one  individual  only  did  we  observe  a miliary  eruption  (Case  64)  ; it  ap- 
peared towards  the  twenty-first  day,  at  the  same  time  that  the  sudamina 
appeared,  and  a slight  diarrhoea  set  in.  The  eruption  covered  a portion  of  the 
chest  and  abdomen,  continued  from  three  to  four  days,  and  seemed  to  contribute 
towards  the  crisis  of  the  disease. 

An  anormal  eruption  somewhat  resembling  purpura  appeared  over  the  chest 
and  epigastrium  in  the  subject  of  Case  11,  about  fourteen  days  after  his  health 
began  to  be  impaired.  This  eruption  lasted  but  twenty -four  hours,  and  appeared 
to  exert  no  influence  on  the  case. 

In  some  of  our  cases,  as  in  Case  20  and  72,  varioloid  pustules  were  observed. 
In  one  individual  these  pustules  covered  the  epigastrium  at  the  time  when 
ataxo-adynamic  symptoms  of  a very  bad  character  existed  ; they  brought  no 
relief ; in  another  patient  they  again  appeared  first  on  the  epigastrium,  and  then 
extended  to  the  thighs.  They  were  observed  to  appear  at  the  same  time  that 
nature  seemed  to  make  an  effort  towards  a cure.  Again,  in  another  case  they 
were  observed  during  convalescence  ; they  appeared  successively  on  the  thighs, 
face,  and  on  the  arm  (Case  72). 

In  cases  of  bad  fever,  the  skin  very  readily  becomes  gangrenous,  or  ulcerates 
in  those  points  where  it  has  been  the  seat  of  slight  irritation.  Where  the  skin 
remains  for  some  time  subjected  to  some  pressure,  and  where  a sanguineous 
congestion,  entirely  of  a mechanical  nature,  takes  place,  this  species  of  passive 
hyperemia  is  very  often  followed  by  an  eschar ; and  when  the  latter  is  detached, 
the  ulceration  which  ensues  from  it  rapidly  extends  in  depth,  and  attacks  even 
the  bones.  This  is  observed  principally  in  the  region  of  the  sacrum,  and  of 
the  great  trochanter. 

In  the  same  individuals,  more  frequently  than  in  other  patients,  blistered 
surfaces  assume  a brown  colour,  or  evince  a tendency  to  ulcerate.  In  them, 
also,  the  slight  engorgements  occasioned  by  leech-bites  terminate  more  fre- 
quently, than  in  other  cases,  in  a slight  ulceration  of  the  skin.  In  the  place  of 
each  leech-bite  there  is  observed  a solution  of  continuity,  which  seems  to  have 
been  made  with  nippers,  and  around  which  the  skin  exhibits  no  alteration. 
These  ulcerations  occur  most  ordinarily  in  persons  who  are  in  an  advanced  stage 
of  the  adynamic  state  ; and  they  have  always  appeared  to  be  a most  unfavour- 
able sign.  In  one  case,  their  appearance  followed  a profuse  intestinal  hemor- 
rhage.* 

* Whilst  we  acknowledge  that  the  disposition  to  gangrene  of  the  skin  is  less  uncommon  in 
bad  typhoid  fevers  than  in  other  diseases,  we  think  that  even  in  these  fevers  the  frequency  of 
such  a phenomenon  is  much  exaggerated.  With  respect  to  internal  organs,  their  gangrene  is 
still  more  uncommon  than  that  of  the  skin.  With  the  exception  of  the  cases,  which  are  even 
less  numerous  than  has  been  stated,  in  which  we  ascertained  in  the  exanthematous  patches  of 
the  intestine  an  appearance  of  eschar,  our  cases  furnished  us  with  only  one  case  of  gangrene : 
it  was  in  the  lung  of  the  individual  who  forms  the  subject  of  our  fifteenth  case;  and  in  this 
instance  it  was  very  evident  that  this  gangrene  was  merely  accidental,  and  altogether  indepen- 
dent of  the  principal  disease.  How  often  have  we  not  heard  of  the  frequency  of  gangrene  in 
fevers  called  adynamic,  putrid,  &c.  ? What  consequences  have  not  been  drawn  from  it,  with 
respect  to  the  nature  of  these  diseases?  In  this  case,  as  in  a thousand  others,  as  in  that  where 
it  is  supposed  that  everything  can  be  explained  in  bad  fevers,  either  by  the  alteration  of  the 
blood,  or  by  gastro-intestinal  irritation,  we  shall  repeat  what  Sydenham  said  of  several  physi- 
cians of  his  time:  Si  quando  symptoma  aliquod,  quod  cum  dicta  hypothesi  apposite  quadrat, 
revera  morbo  competat,  cujus  typum  delineaturi  sunt,  turn  illud  supra  modum  evehunt,  ac  plane 
reddunt  ex  mure  elephantem,  quasi  in  hoc  scilicet  totius  rei  cardo  verteretur,  sin  hypothesis 
minus  congruat,  aut  prorsus  silentio,  aut  levi  saltern  pede  transmittere  consueverunt,  nisi  forte 
beneficio  subtilitatis  alicujus  philosophic®  in  ordinem  cogi  ac  quoquo  modo  accommodari 
possit. 


DISEASES  OF  THE  ABDOMEN. 


197 


ARTICLE  HI. 

TREATMENT. 

In  the  preceding  cases,  we  have  seen  the  patients  who  form  the  subjects  of 
them,  subjected  to  the  most  different  modes  of  treatment.  Some  took,  during 
the  entire  progress  of  this  disease,  nothing  but  simple  diluents  of  an  acidulous 
or  mucilaginous  nature:  they  observed  strict  regimen  and  repose,  and  no  active 
treatment  was  employed  with  them.  Others  took  no  other  medicine  internally 
than  these  same  diluents  ; but  bloodletting,  to  a greater  or  less  extent,  was 
resorted  to.  In  several,  the  skin  was  covered  with  sinapisms,  or  blisters,  or 
irritated  by  stimulant  frictions.  In  some,  cold  applications  were  made  to  the 
head,  and  baths  of  various  temperatures  were  employed.  Purgatives,  and  more 
frequently  emetics,  were  employed  in  a considerable  number  of  cases ; and 
lastly,  with  others,  atonic  and  stimulant  treatment  was  adopted.  Several,  either 
at  the  same  period,  or  at  different  stages  of  their  illness,  were  treated,  at  one 
and  the  same  time,  or  successively,  by  two,  three,  or  four  of  these  methods. 

If  we  now  endeavour  to  estimate  the  influence  of  these  different  modes  of 
treatment,  we  shall  find  the  most  serious  difficulties  in  the  inquiry.  For  all  we 
might  cite  instances  of  success,  and  for  all  even  the  reverse,  according  as  we 
should  dwell  more  particularly  on  that  one  or  the  other;  it  would  be  easy,  then, 
to  find  motives  for  preferring  or  excluding  such  or  such  a treatment ; we  might 
even  take  a more  convenient  station,  and  say  that,  according  to  the  cases,  such 
or  such  a treatment  should  be  preferred.  But  whilst  thus  confining  ourselves 
to  the  generalities  of  the  question,  we  should  not  make  much  advance  in  it,  and 
certainly  we  should  not  be  able  to  solve  it,  because  the  elements  of  its  solution 
do  not  exist  in  our  cases.  It  seems  to  us  that  whatever  may  be  the  method  of 
treatment  employed,  there  is  a certain  number  of  cases  in  which  nature  con- 
ducts the  affection  to  a favourable  or  fatal  termination,  without  the  treatment 
having  any  share  in  the  result.  From  this,  however,  it  must  not  be  inferred, 
that  our  therapeutic  means  exercise  no  influence  on  the  progress  and  mode  of 
termination  of  fevers.  But  if  nature  performs  so  considerable  a part  here,  it  is 
manifest  that  in  order  to  appreciate 'the  influence  of  the  treatment,  whether  it 
be  injurious  or  serviceable,  it  is  necessary  to  collect  and  subject  to  a rigorous 
examination  a much  greater  number  of  facts  than  ours,  to  the  end  that,  the 
same  results  being  reproduced  a great  number  of  times,  we  may  be  able  to 
calculate  what  belongs  to  nature  and  what  belongs  to  art.  The  writers  on  epi- 
demic diseases  have  not  proceeded  in  this  way,  the  majority  of  them  thinking 
it  sufficient  to  point  out,  in  a general  way,  what  treatment  has  appeared  to  them 
to  succeed  best.  The  treatment  which  was  deemed  most  successful  in  their 
hands  was  almost  invariably  that  which  was  suggested  to  them  by  the  theory 
under  whose  influence  they  observed  the  diseases.  Thus,  very  little  advantage 
can  be  derived  from  what  they  have  transmitted  to  us  as  the  result  of  their 
experience  in  therapeutics.  It  would  not  have  been  so,  if,  instead  of  general 
results,  they  had  drawn  up  tables  exhibiting  the  number  of  patients  subjected  to 
such  or  such  a mode  of  treatment.  The  man  who  merely  publishes  some  cases 
and  observations  on  a disease,  should  do  nothing  else  than  note  a simple 
coincidence  between  the  employment  of  such  or  such  a treatment,  and  the 
favourable  or  unfavourable  termination  of  the  disease.  It  is  only  when  this 
coincidence  has  been  repeated  very  frequently,  that  it  is  allowable  to  consider 
as  connected  together  two  facts  which  presented  themselves  together  so  fre- 
quently. By  collecting  the  numerous  observations  published  by  men  of  all 
opinions  on  this  particular  point,  we  think  that  the  treatment  of  fever  might  be 
17* 


198 


ANDUAL’S  MEDICAL  CLINIC. 


not  a little  benefited.  However  important  this  subject  may  appear  to  us,  the 
nature  of  this  work  does  not  allow  us  to  dwell  on  it.  Without  going  beyond 
our  own  cases,  and,  consequently,  without  intending  to  draw  any  general  con- 
clusions, we  shall  endeavour  to  recapitulate,  in  a few  words,  the  various  phe- 
nomena observed  in  our  patients  whilst  they  were  submitted  to  different  kinds 
of  treatment.  We  shall  present  each  mode  of  treatment  separately,  and  shall 
trace  the  changes  which  coincided  with  their  employment ; first,  in  the  general 
aspect  of  the  disease  ; secondly,  in  its  principal  symptoms.  This  will  be  a com- 
mencement of  the  great  work  which  we  would  wish  to  see  undertaken  by  collect- 
ing, in  a therapeutic  point  of  view,  the  numerous  cases  of  fevers  scattered 
through  different  authors.  We  shall  add,  that  even  this  work  can  be  useful 
only  on  this  condition,  that  it  should  not  be  forgotten  that  the  number  of  suc- 
cessful, as  well  as  that  of  unfavourable  results,  constitutes  in  a, manner  but  an 
ideal  majority  ; for  very  few  authors  have  published  all  the  cases  observed  by 
them,  and  the  greater  number  of  them  have  been  solicitous  to  transmit  to  us 
those  cases  only  which  favoured  their  own  theories.  Read,  for  example,  the 
cases  published  by  the  disciples  of  Brown  ; you  will  there  find  no  instance  of 
bad  fever  successfully  treated  by  bloodletting;  still  these  cases  exist,  and  they 
must  have  seen  them  as  well  as  we.  Read,  on  the  other  hand,  the  collections 
of  cases  published  by  the  followers  of  M.  Broussais’  school  ; you  will  not  find 
therein  a single  case  of  these  same  diseases  which  recovered  when  treated  by 
tonics ; and  yet  such  cases  must  have  occurred  on  all  sides  of  them,  and  they 
must  have  seen  them. 


SECTION  I. 

TREATMENT  BY  STRICT  DIET,  AND  MUCILAGINOUS  OR  ACIDULATED 

DRINKS. 

A considerable  number  of  our  patients  were  subjected  to  this  mode  of  treat- 
ment. In  some  the  affection  was  slight,  in  others  it  was  severe  ; and  we  ob- 
served the  various  symptoms  of  typhoid  fever,  such  as  the  various  phenomena 
regarding  the  innervation,  delirium,  stupor,  prostration,  tongue  dry  or  black, 
meteorism,  petechiae,  etc. 

During  the  employment  of  this  mode  of  treatment  we  observed  all  the  symp- 
toms to  improve  in  several,  and  the  disease  to  terminate  as  promptly  and  as 
favourably  as  in  others  placed  under  similar  circumstances,  and  with  whom 
bloodletting  was  employed.  We  have  frequently  seen  a severe  attack  of  fever 
terminate  in  twenty-four  or  forty-eight  hours  in  persons  in  whom  the  disease 
was  occasioned  by  bad  living,  and  who  were  rapidly  restored  to  health  by  strict 
regimen  and  rest,  and  nothing  further. 

We  are  not  disposed  to  think  that  continued  fevers,  thus  left  to  nature,  had  a 
determinate  duration,  and  that  they  terminated  on  certain  days  rather  than  on 
others  ; and  with  respect  to  these  affections,  the  ancient  doctrine  of  critical  days 
appeared  to  us  completely  erroneous. 

With  respect  to  crises,  should  they  not  be  particularly  evident  in  those  cases 
wherein  no  active  treatment  had  interrupted  or  thwarted  what  is  called  the  pro- 
gress of  nature  ; still  the  phenomena  to  which  the  name  of  crisis  has  been  given 
did  not  mark  the  termination  of  the  disease  except  in  a very  small  number  of 
eases.  In  only  four  did  the  appearance  of  a profuse  sweat  coincide  with  the 
cessation  of  the  fever,  and  the  other  morbid  phenomena.  In  other  cases  there 
was  still  some  sweating  towards  the  termination  of  the  disease  ; but,  from  the 
circumstances  under  which  it  appeared,  even  the  ancients  would  have  hesitated 
to  assign  to  it  a critical  character.  As  an  instance  of  this,  we  may  refer  to  the 
young  girl  who  forms  the  subject  of  our  49th  caso.  In  her  an  habitual  sweat  from 


DISEASES  OF  THE  ABDOMEN. 


199 


the  axilla  was  restored  as  soon  as  convalescence  commenced.  But,  in  this  case, 
can  we  see  anything  else  but  the  re-establishment  of  a secretion,  which  had 
actually  become  an  element  of  health,  which  had  been  suppressed  by  the  disease, 
and  which  must  reappear  from  the  moment  the  disease  ceases  ? Still  less  shall 
we  consider  other  sweats  as  critical,  which,  under  the  influence  of  the  expectant 
method,  the  results  of  which  we  are  now  examining,  appeared  long  before  the 
termination  of  the  disease.  In  fact,  in  several  individuals,  also  treated  in  this 
way,  no  sweat,  nor  any  other  critical  phenomenon,  was  observed.  In  the  sub- 
ject of  case  13th,  who,  during  his  tedious  and  severe  illness,  was  also  treated 
according  to  the  expectant  method,  one  of  the  lower  extremities  became,  during 
convalescence,  the  seat  of  a profuse  suppuration,  which  carried  the  patient  to 
the  grave. 

Besides  those  patients  with  whom  the  expectant  method  alone  was  employed, 
there  are  others  who  were  treated  according  to  it  only  at  the  commencement  of 
their  illness ; at  a later  period  an  active  treatment  was  employed  to  check  the 
increasing  progress  of  the  disease ; sometimes  an  evident  improvement  followed 
this  change  of  treatment ; but  sometimes,  too,  the  disturbance  occasioned  in  the 
system  by  the  active  treatment  employed  was  not  more  advantageous  than  the 
expectant  system  had  been  salutary,  and  the  disease  still  progressed  towards  a 
fatal  termination. 

Other  patients,  on  the  contrary,  were  subjected,  from  the  very  commencement, 
to  different  sorts  of  treatment  more  or  less  active.  No  benefit  resulted  from  it, 
and  the  disease  continued  stationary,  or  became  worse.  It  was  under  these 
circumstances  that,  giving  up  all  active  treatment,  we  contented  ourselves  with 
keeping  the  patients  on  diet  and  simple  diluent  drinks ; only,  in  some  instances, 
weak  broths,  or  a little  wine,  were  added  to  these  drinks.  Some  of  our  cases 
furnish  us  with  instances  in  which  a return  to  the  expectant  method  was  attended 
with  advantage.  We  discontinued  to  torment  nature  with  remedies  which  were 
followed  by  no  improvement;  we  contented  ourselves  with  removing  everything 
which  could  do  harm,  and  the  cure  was  the  result  of  the  mere  effort  of  nature, 
aided  by  simple  hygienic  means. 

If  we  now  wish  to  appreciate  the  influence  of  the  simple  expectant  method 
over  the  great  functional  disturbances  of  the  different  organs,  we  shall  come  to 
the  following  results  : — 

Let  us  first  study  its  influence  on  disturbances  of  the  digestive  passages. 

Anorexia.  Bad  taste  in  the  mouth  has  in  general  disappeared  only  by  degrees, 
in  persons  submitted  to  this  mode  of  treatment.  In  several  instances  diet  and 
diluents,  continued  for  a long  time,  proved  unable  to  remove  these  symptoms, 
which,  in  the  individuals  who  form  the  subjects  of  those  cases,  yielded  rapidly 
to  the  use  of  evacuants. 

Some  entered  the  hospital  with  vomiting,  which  continued  as  long  as  they 
took  nothing  but  diluents,  and  which  afterwards  ceased  after  the  employment  of 
other  means,  as  we  shall  see  presently. 

Under  the  influence  of  the  expectant  method,  the  tongue,  in  several  instances, 
presented  no  change,  and  its  aspect  was  not  altered  till  other  treatment  was  tried. 
Thus,  in  some  cases,  it  retained  its  uniform  whiteness,  its  yellowish  coat  in 
others,  its  white  appearance,  with  red  points,  in  several;  in  others,  its  uniform 
red  colour,  with  continuance  of  its  moisture;  and  in  others  its  redness  and  dry- 
ness ; in  others,  too,  its  black  appearance.  In  these  latter  cases  we  were  enabled 
to  see  that  it  is  not  true,  as  has  been  stated,  that  it  is  only  after  the  employment 
of  tonic  medicines  that  the  tongue  becomes  black. 

In  several  other  persons,  who  were  also  subjected  to  the  same  treatment,  not 
only  the  state  of  the  tongue  was  not  improved,  but  this  organ  assumed  an  ap- 
pearance corresponding  with  the  increase  in  the  severity  of  the  other  symptoms 
of  the  disease.  We  have,  for  instance,  seen  it  become  redder  and  redder,  and 


200 


ANDRAL’S  MEDICAL  CLINIC. 


also  become  dry,  brown,  and  incrusted  in  cases  25  and  64,  as  well  as  in  a few 
others. 

To  conclude,  in  some  patients,  who,  like  the  preceding,  do  nothing  but  observe 
strict  diet  and  drink  barley  water,  the  tongue  throws  off  its  coats,  resumes  its 
moist  appearance,  and  returns  slowly  or  rapidly  to  its  normal  state.  In  one  case 
the  tongue,  which  was  covered  with  a thick  yellowish  coat  at  the  time  the  patient 
entered  the  hospital,  became  red  and  dry  as  soon  as  bleeding  was  resorted  to. 
The  patient  was  then  treated  according  to  the  expectant  method.  At  first  the 
tongue  remained  red  and  very  dry;  it  was  then  observed  gradually  to  recover  its 
natural  appearance,  at  the  same  time  that  the  other  symptoms  became  improved. 
The  same  may  be  said  of  two  other  cases,  in  both  of  which  the  dryness  of  the 
tongue  appeared  or  increased  after  bloodletting,  and  gradually  recovered  its 
moisture  and  red  colour;  once  the  disease  was  left  to  nature.  In  one  or  two 
cases  the  foulness  of  the  tongue  was  not  at  all  influenced  by  bloodletting,  whilst 
the  employment  of  the  expectant  method  gradually  restored  the  organ  to  its 
natural  state.  In  some  of  our  patients  the  tongue,  which  was  red  and  more  or 
less  dry  at  the  time  of  their  admission,  gradually  recovered  its  normal  appear- 
ance without  the  employment  of  any  active  treatment.  In  two  or  three  other 
cases  the  brown  or  black  colour  of  the  tongue  also  disappeared  under  the  sole  in- 
fluence of  diet  and  diluents,  no  other  treatment  having  been  employed.  In 
others,  again,  the  uniform  whitish  coat  which  covered  the  tongue  disappeared 
without  anything  else  having  been  prescribed  but  diet  and  acidulated  or  muci- 
laginous drinks. 

In  several  of  the  cases  the  diarrhoea  was  neither  increased  nor  diminished  by 
the  expectant  method  of  treatment.  In  one  case  it  appeared  for  the  first  time 
whilst  the  patient  was  under  this  mode  of  treatment.  It  at  first  increased  in  one 
of  our  patients  ; then,  after  an  ineffectual  application  of  leeches  to  the  anus,  it 
gradually  ceased.  Again,  under  the  influence  of  the  mere  expectant  treatment, 
the  diarrhoea  gradually  diminished  in  a great  number  of  our  cases.  Of  these 
latter  some  had  not  been  subjected  to  any  active  treatment ; others  had  at  first 
been  bled,  which  did  not  appear  to  exercise  any  influence  on  the  diarrhoea.  In 
one  patient,  one  of  those  put  on  the  expectant  method  of  treatment,  the  diarrhoea 
disappeared  suddenly  at  the  same  time  that  a perspiration  set  in. 

The  mere  observance  of  strict  diet,  and  the  use  of  diluent  drinks,  have  been 
followed  by  the  slow  or  rapid  disappearance  of  the  febrile  disturbance  in  several 
cases.  This  same  treatment  put*  a termination  to  the  fever  after  we  had  inef- 
fectually tried  bloodletting  in  some  cases,  evacuants  in  others,  and  tonics  in 
several. 

Lesions  of  the  respiratory  apparatus  have  not  been  more  common  in  persons 
treated  by  simple  diluents  than  in  those  submitted  to  a more  active  treatment. 
Pneumonia  being  once  developed  has  not,  generally  speaking,  been  left  to  itself, 
when  once  its  existence  has  been  ascertained. 

Some  individuals,  in  whom  the  nervous  symptoms  predominated,  have  been 
submitted  exclusively  to  the  expectant  method.  In  the  subjects  of  some  of  our 
cases,  the  stupor,  delirium,  prostration,  and  coma  disappeared,  whilst  the  patients 
took  nothing  but  barley  water.  In  others  these  same  symptoms,  ineffectually 
met  by  bloodletting,  gradually  disappeared  under  the  influence  of  a simple  ex- 
pectant method  of  treatment.  In  others  this  method,  at  first  employed  singly, 
did  not  prevent  the  nervous  symptoms  from  appearing  and  increasing;  but  in 
these  cases  the  other  methods  substituted  for  it  (antiphlogistics  or  tonics)  were 
not  more  serviceable.  Again,  in  other  cases,  the  nervous  symptoms,  which 
became  more  and  more  developed  while  simple  diluent  drinks  were  employed, 
disappeared  as  soon  as  tonics  were  substituted  for  them. 

The  antiphlogistic  treatment  and  the  tonic  treatment  have  been,  each  in  its 
turn,  accused  of  producing  petechiae.  However,  in  several  of  our  cases  these 
spots  appeared  at  a period  when  no  active  treatment  had  been  as  yet  employed. 


DISEASES  OF  THE  ABDOMEN. 


201 


An  eruption  of  sudamina  also  appeared  in  one  patient,  when  he  had  not  yet 
taken  anything  but  barley  ptisan. 

SECTION  II 1 

TREATMENT  BY  BLOODLETTING. 

Bloodletting  was  employed  in  a very  great  number  of  our  patients.  Whilst 
it  was  evidently  serviceable  in  some,  it  proved  ineffectual  in  others;  and  in  seve- 
ral its  employ  ment  was  followed  so  rapidly  by  an  exacerbation  of  the  symptoms, 
that  we  have  been  disposed,  in  more  than  one  case,  to  attribute  the  change  to  it. 
However  we  must  not  lose  sight  of  several  circumstances  which  might  have  con- 
tributed to  render  bloodletting  much  less  effectual  in  these  cases.  In  the  first 
rank  we  must  place  the  advanced  period  at  which  several  patients  were  bled  for 
the  first  time  ; some  already  presented  a state  of  prostration,  which  was  almost 
invariably  increased  after  the  bleeding.  In  some  the  bleeding  seemed  to  do  harm 
by  being  excessive  ; in  others,  on  the  contrary,  the  leech-bites  yielded  so  little 
blood,  that  the  good  or  harm,  following  their  application,  could  not  be  fairly  at- 
tributed to  them.  Again,  in  many  cases,  it  was  difficult  to  distinguish  the  real 
influence  exercised  by  bleeding,  because  it  was  not  the  only  means  employed, 
and  oftentimes,  either  simultaneously  with  it,  or  previously  or  subsequently  to 
it,  other  means  had  been  resorted  to  — sometimes  cutaneous  revulsives,  some- 
times tonics  and  internal  stimulants,  and  sometimes  evacuants. 

Several  patients  as  yet  presented  no  bad  symptom  when  they  were  bled  ; they 
merely  exhibited  that  group  of  symptoms  of  what  is  called  bilious-or  inflamma- 
tory fever ; after  the  bleeding,  the  state  of  some  became  suddenly  worse.  In 
others  no  change  was  observed  at  first ; then  the  disease  gradually  progressed 
towards  a fatal  termination.  In  this  case  the  bleeding  exercised  but  a purely 
negative  influence  ; it  did  not  arrest  the  evil ; but  it  is  a matter  of  doubt  whether 
it  may  not  have  contributed  to  increase  it.  The  number  of  patients  in  whom 
the  affection  became  worse  immediately  after  bleeding  was  greater  than  the 
number  of  those  in  whom  the  affection  continued  to  go  on  in  the  same  way  as  it 
had  before  the  patients  had  lost  any  blood. 

In  a few  of  our  cases  the  first  bleeding  was  followed  by  a manifest  improve- 
ment, which  disappeared  after  the  bleeding  was  repeated. 

Of  thirty-five  individuals  who  were  bled,  and  whose  illness  terminated  fatally, 
seven  were  bled  at  the  onset  of  the  disease,  from  the  first  to  the  fourth  day. 
Nine  lost  blood  from  the  fourth  day  exclusively  to  the  eighth  inclusively.  In 
five  bleeding  was  employed  from  the  eighth  to  the  twelfth  day.  Three  were 
bled  from  the  twelfth  to  the  sixteenth  day.  In  the  others  blood  was  taken  at 
periods  which  we  cannot  state  precisely,  but  in  most  instances  it  was  at  a time 
remote  from  the  onset  of  the  disease. 

We  shall  now  speak  of  other  patients  who  recovered  after  having  been  sub- 
jected, like  the  preceding,  to  one  or  more  bleedings.  The  bleeding  was  far  from 
having  the  same  influence  on  all.  Some  manifested  a sudden  improvement 
after  losing  blood  ; in  them  it  was  scarcely  possible  to  doubt  the  advantage  of 
the  bleeding.  This  occurred  in  thirteen  of  our  cases.  But  in  none  of  these 
thirteen,  except  one,  was  the  disease  suddenly  removed  by  the  bleeding  ; the 
symptoms  merely  were  improved,  and  probably  its  duration  shortened.  It  is 
not,  then,  so  very  common  an  occurrence  to  see  a disease  suddenly  arrested, 
and,  as  it  were,  strangled  by  bloodletting.  Such  a claim  for  its  beneficial  effects 
is  entirely  unsupported  by  clinical  experience. 

In  one  case  the  first  application  of  leeches  to  the  anus  was  not  followed  by 
any  change  : they  were  applied  a second  time,  and  a rapid  improvement  took 
place. 


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ANDRAL’S  MEDICAL  CLINIC. 


In  another  case  no  improvement  followed  the  first  bleeding,  which  was  em- 
ployed on  the  sixth  day ; after  a second,  which  was  employed  from  the  eighth 
to  the  ninth  day,  all  the  symptoms  suddenly  disappeared  at  the  same  time  that 
a perspiration  came  on. 

In  another  the  disease  improved  after  the  first  bleeding  ; then,  a very  little 
time  after,  a new  exacerbation  of  the  symptoms  was  observed,  which  disappeared 
after  the  application  of  leeches. 

Of  these  thirteen  patients  some  were  bled  during  the  first  days  of  their  illness, 
but  others  of  them  not  till  the  seventh  or  eighth  day  ; others  at  a still  more  ad- 
vanced period,  as  towards  the  fourteenth  day.  In  the  young  girl  who  forms  the 
subject  of  one  of  our  cases,  leeches  were  repeatedly  applied  during  the  entire 
course  of  the  disease  ; they  were  continued  at  a time  when  the  prostration  was 
very  great. 

We  shall  now  consider  the  influence  of  bloodletting  in  the  twenty-six  other 
individuals,  who  also  recovered  after  having  lost  more  or  less  blood.  Very 
different  from  the  thirteen  above  mentioned,  they  manifested  no  improvement 
immediately  after  they  were  bled.  Thus  we  saw  the  disease  pursue  its  course, 
then  diminish  progressively  without  seeming  to  have  been  in  any  way  influ- 
enced by  the  treatment  in  several  of  these  cases.  Of  these  there  were  two, 
however,  in  whom  the  bleeding  seemed  to  have  been  beneficial,  not  against  the 
principal  disease  itself,  but  to  arrest  the  progress  of  a pneumonia  which  super- 
vened. 

Again,  in  some  other  individuals,  the  disease  became  worse  so  suddenly 
after  bleeding,  that  the  latter  measure  seemed  to  us  to  have  contributed  to  this 
effect,  and  the  improvement  did  not  commence  till  a certain  time  after  its  employ- 
ment. 

In  these  twenty-six  cases  the  bleeding  was  seldom  practised  at  the  commence- 
ment, but  most  frequently  at  a more  advanced  period  of  the  disease. 

To  recapitulate,  among  nearly  eighty  individuals  labouring  under  continued 
fever,  light  or  severe,  and  treated  by  bloodletting,  local  or  general,  we  find  but 
sixteen  in  whom  a visible  improvement,  which  cannot  be  called  in  doubt,  imme- 
diately follows  the  opening  of  the  vein  or  the  application  of  leeches.  And 
again,  of  these  sixteen  cases  there  are  three  in  whom  the  amendment  disappeared 
after  the  bleeding  was  repeated.  Observe,  again,  that  in  two  or  three  of  these 
sixteen  cases,  at  most,  the  disease  was  arrested  all  at  once  after  the  bleeding ; 
that  in  all  the  others  it  was  only  improved,  and  that  this  improvement  was  prin- 
cipally marked  when  the  period  at  which  the  bleeding  was  performed  coincided 
with  that  when,  in  our  patients  treated  according  to  the  simple  expectant 
method,  we  saw  that  there  was  tendency  to  a similar  improvement  taking  place 
spontaneously. 

Of  the  remaining  individuals,  we  find  thirty-four  in  whom,  after  one  or  more 
bleedings,  the  disease  still  continues  its  course,  so  as  to  terminate  in  death,  or  in 
a return  to  health.  Here  the  bleeding  no  longer  has  any  immediate  influence  ; 
but  it  is  not  unreasonable  to  think,  that  in  several  of  these  cases  it  might  dispose 
to  a favourable  termination  of  the  disease. 

In  twenty-four  other  cases  we  observe,  after  bloodletting,  an  exacerbation  of 
the  disease,  as  immediate  and  as  marked  as  the  improvement  had  been  in  the 
sixteen  individuals  above  mentioned  ; so  that  the  same  reasoning  which  inclines 
us  to  attribute  the  benefit  which  these  latter  experienced,  to  the  bleeding,  must 
also  make  us  admit  that  it  was  the  bleeding  which  rendered  the  state  of  the 
former  worse.  For  our  part,  we  shall  take  all  these  facts  into  account ; we  shall 
reflect  on  all  the  details  of  each  case,  in  order  to  discover  the  circumstances  which 
could  have  occasioned  such  opposite  results.  But  we  shall  feel  that  we  have 
only  laid  down  some  corner-stones  ; and  we  shall  wait  till  sufficient  materials 
have  been  amassed,  in  order  to  think  ourselves  warranted  in  pronouncing  on  the 


DISEASES  OF  THE  ABDOMEN. 


203 


benefit  or  injury  which  may  be  attributed  to  the  bleeding  in  these  different 
cases. 

Let  us  now  consider  what  was  the  influence  exercised  by  bloodletting  on 
some  of  the  most  prominent  functional  disturbances  observed  in  the  course  of 
fever ; and  before  we  go  further,  we  shall  say,  that  in  a great  number  of  cases 
these  functional  disturbances,  thus  examined  one  by  one,  are  found  to  be  much 
less  modified  by  bleeding,  then  one  would  have  been  inclined  to  admit  a 
priori . 

Thus,  in  a considerable  number  of  our  patients,  the  anorexia,  and  bad  taste  in 
the  mouth,  were  not  lessened  after  venesection,  or  after  the  application  of  leeches 
either  to  the  abdominal  parietes-  or  to  the  anus. 

In  several  cases,  where  acute  pain  existed,  which  was  increased  by  pressure, 
whether  at  the  epigastrium,  in  the  ileo-caecal  region,  around  the  umbilicus,  or 
over  the  entire  abdomen,  bleeding  was  immediately  followed  by  the  disappear- 
ance of  this  pain.  In  the  subject  of  one  of  these  cases,  one  general  bleeding  was 
all  that  was  employed.  In  the  others  so  affected,  leeches  were  applied,  either 
to  the  anus,  or  to  the  abdominal  parietes.  The  subject  of  one  of  these  cases  had 
a very  acute  pain  in  the  epigastrium,  which  disappeared  after  this  part  had  been 
covered  with  leeches.  Another  of  these  individuals  complained  of  pains  over 
the  entire  abdomen,  which  were  exasperated  after  the  employment  of  an  emetic  ; 
in  this  case  there  was  this  peculiarity,  that  the  leeches,  instead  of  being  applied 
over  the  abdomen,  or  to  the  anus,  were  applied  to  each  side  of  the  chest  in  con- 
sequence of  a distressing  cough  under  which  the  patient  laboured  ; the  day 
after  the  leeches  were  so  applied,  there  was  no  longer  any  trace  of  abdominal 
pain. 

But  we  were  far  from  succeeding  in  removing  this  pain  by  bloodletting  in  all 
the  cases  wherein  it  existed.  In  one  case,  it  became  merely  less  intense,  but 
did  not  disappear,  after  a general  bleeding.  In  two  other  cases,  wherein  the 
vein  was  opened,  but  in  which  no  leeches  were  applied,  it  continued  without 
any  abatement.  In  another  patient,  the  general  pain  of  the  abdomen  still  con- 
tinued after  bleeding ; but  it  disappeared  after  the  application  of  leeches  to  the 
anus. 

The  different  appearances  of  the  tongue  in  fever  may  be  very  differently  mo- 
dified by  bloodletting,  as  the  following  recapitulation  will  show  : 

First  Case. — Tongue  covered  with  a white  or  yellow  coat,  without  any  trace  of  redness, 

still  remaining  moist. 

Nineteen  individuals  presented  this  appearance  of  the  tongue,  when  blood- 
letting began  to  be  used.  In  ten  of  them,  the  tongue  did  not  change  its  appear- 
ance after  bleeding.  In  seven  others,  a very  remarkable  change  was  observed 
in  the  appearance  of  the  tongue  after  bleeding;  in  some  it  became  red  ; in  others 
dry  and  black.  In  only  two  of  these  nineteen  individuals,  did  the  tongue  re- 
sume its  natural  appearance  ; and  we  must  again  observe,  that  in  one  of  these 
this  return  of  the  tongue  to  its  natural  appearance  did  not  take  place  sud- 
denly. 

Second  Case. — Tongue  red,  with  or  without  the  admixture  of  any  coat,  still  retaining  its 

moist  appearance.* 

Twenty-three  persons  presented  this  appearance  of  the  tongue,  when  blood- 
• letting  began  to  be  employed  with  them. 

* Under  this  second  case  we  include,  first,  the  tongues,  which  are  of  a uniform  more  or  less 
bright  red  through  their  entire  extent,  without  being  covered  with  any  coat ; secondly,  those 
which  present  a white  or  yellow  coat  with  red  points  ; thirdly,  those  which,  being  white  or 
yellow  at  the  centre,  present  a red  appearance  at  their  edge  or  apex. 


204 


ANDRAL’S  MEDICAL  CLINIC. 


In  eight  of  them  the  tongue  underwent  no  -change  after  the  bleeding.  In 
three  others  it  became  dry  immediately  after  the  patients  had  lost  blood.  In 
another  it  became  dry  after  two  bleedings  had  been  performed,  with  a very 
short  interval  between  them.  Still,  notwithstanding  this  unfavourable  sign,  the 
patient  was  bled  a third  time ; after  which  the  tongue  not  only  became  moist, 
but  also  lost  its  redness. 

In  another  case  the  tongue  became  covered  with  a thick  yellowish  coat  after 
venesection. 

To  conclude  ; in  ten  of  these  twenty-three  individuals,  the  bloodletting  was 
rapidly  followed  by  the  return  of  the  tongue  to  its  normal  state.  In  some  of 
them  leeches  were  applied  to  the  anus,  or  to  the  sides  of  the  chest.  In  the 
others,  venesection  was  the  mode  employed. 

Third  Case. — Tongue  dry,  either  with  a uniform  red  colour,  or  with  a pale  colour ; or  with  a 
white  or  yellow  coat  on  its  surface. 

Nineteen  individuals  presented  this  appearance  of  the  tongue  when  they  were 
bled.  In  four  of  them  the  tongue  underwent  no  change  after  bleeding.  In  a 
fifth  the  tongue  became  moist  at  first,  after  the  application  of  leeches  to  the  anus  ; 
it  afterwards  soon  resumed  its  dry  appearance,  which  was  not  removed  by  a 
second  application  of  leeches. 

In  ten  cases  the  tongue  became  drier,  or  black,  after  bleeding.  In  one  of 
these  cases  leeches  were  applied  to  the  epigastrium  several  days  in  succes- 
sion. 

In  only  four  cases  did  the  tongue  become  moist  immediately  after  bleeding. 
In  one  the  dryness  of  the  tongue  did  not  disappear  after  the  first  loss  of  blood. 
On  the  contrary,  the  tongue  began  to  become  drier  after  the  first  application  of 
leeches  to  the  anus  ; it  became  moist,  but  changed  the  yellow  coat  which 
covered  it  into  a bright  red  after  a general  bleeding ; at  length  it  recovered  its 
normal  appearance,  after  a second  application  of  leeches  to  the  anus. 

Fourth  Case. — Tongue  dark-coloured,  with  or  without  incrustation  of  the  lips  and  teeth.* 

Only  four  persons  were  treated  by  bloodletting,  with  such  an  appearance  of 
the  tongue.  In  three  of  them  this  appearance  continued  after  the  bleeding. 
However,  in  one  of  these  three  individuals  the  tongue,  without  having  lost  its 
black  colour,  appeared  more  moist  the  day  after  leeches  were  applied  to  the 
anus;  and  as  a tonic  treatment  was  immediately  commenced,  the  ulterior  effects 
of  the  bleeding,  with  respect  to  the  tongue,  can  no  longer  be  appreciated. 

In  the  fourth  of  these  cases  the  dark  appearance  of  the  tongue  increased  after 
fifteen  leeches  had  been  applied  to  the  anus.  Forty-five  patients  were  treated 
with  bloodletting  during  the  existence  of  diarrhoea,  more  or  less  severe. 

Of  these  forty-five  individuals,  there  are  nineteen  in  whom  venesection  was 
performed  once  or  oftener  ; and  twenty-six  others  in  whom  leeches  were  em- 
ployed in  different  points  ; in  nineteen  cases  to  the  anus  (once  or  oftener)  ; in 
three  cases  to  the  abdominal  parietes  ; in  four  cases  to  other  parts,  either  behind 
the  ears,  or  to  the  neck,  or  the  chest. 

Let  us  now  consider  the  influence  exercised  on  the  diarrhoea  by  these  differ- 
ent modes  of  bleeding. 

1st.  General  bleeding.  — It  possessed  no  influence  over  the  diarrhoea  in 
eleven  cases  in  which  it  was  employed.  In  two  cases  it  was  followed  by  slight 

* Since  these  cases  were  collected,  we  have  often  tried  the  application  of  leeches  to  the  anus, 
and  particularly  to  the  epigastrium,  in  patients  whose  tongue  was  dry  and  black,  or  only  viscid 
and  brown  ; and  the  general  impression  on  our  minds  from  such  trials  is,  that  in  the  very 
great  majority  of  cases,  the  bloodletting  had  at  least  no  beneficial  influence  on  this  state  of  the 
tongue.  This  has  also  been  laid  down  by  M.  Broussais. 


DISEASES  OF  THE  ABDOMEN.  205 

diminution  of  the  purging,  hut  it  did  not  stop  it.  In  five  cases  the  diarrhoea 
was  increased  after  venesection. 

We  may  add,  that  in  some  patients  who  had  no  purging  at  the  time  they 
were  bled,  venesection  did  not  prevent  the  occurrence  of  this  symptom. 

2d.  Application  of  leeches. — In  seven  of  our  cases  the  application  of  leeches 
to  the  anus  did  not  prevent  the  continuance  of  the  diarrhoea.  In  one  case  the 
diarrhoea  was  increased  after  this  application.  It  was  diminished  after  this  ap- 
plication in  six  cases.  In  four  of  our  cases  the  application  of  leeches  immedi- 
ately removed  the  diarrhoea  altogether. 

When  applied  in  three  cases  over  the  abdominal  parietes,  once  to  the  ileo- 
caecal  region,  and  twice  to  the  epigastrium,  in  none  of  these  three  cases  did  the 
leeches  exercise  any  influence  over  the  diarrhoea. 

In  the  four  cases  wherein  the  leeches  were  applied  to  other  parts,  different 
from  the  abdomen  or  anus,  no  change  was  produced  in  the  purging. 

Thus  in  twenty-six  individuals,  who  lost  blood  from  other  parts  than  the 
anus,  there  was  not  one  in  whom  the  diarrhoea  ceased  ; in  two  only  it  under- 
went a slight  diminution ; and  in  several  it  was  increased. 

In  nineteen  persons  who  lost  blood  from  the  anus,  we  find  ten  in  whom  the 
diarrhoea  was  lessened,  or  ceased  immediately ; it  increased  in  one  only,  but 
in  seven  it  continued. 

In  one  case  intestinal  hemorrhage  occurred,  after  the  patient  had  been  bled 
several  times  successively. 

Meteorism,  which,  in  bad  fevers,  has  been  often  considered  as  a mere  product 
of  intestinal  irritation,  is  one  of  the  phenomena  of  those  diseases  against  which 
bloodletting  has  appeared  to  us  least  beneficial.  When  this  treatment  was  em- 
ployed during  tile  existence  of  the  meteorism,  it  did  not  stop  it,  or  it  did  not 
even  prevent  it  from  increasing;  and  when  employed  at  a period  when  the 
meteorism  did  not  yet  exist,  bloodletting,  whether  general  or  local,  has  been 
rapidly  followed  by  the  appearance  of  this  symptom  in  several  cases.  We  shall 
further  observe,  that  of  the  seventy-four  cases  in  which  bloodletting  was  em- 
ployed, that  were  but  sixteen  in  whom  we  saw  the  meteorism  occur  after  this 
bleeding  ; it  would,  therefore,  be  premature  to  say  that  it  contributed  to  its  pro- 
duction ; and  all  that  can  be  inferred  is,  that  the  bloodletting  did  not  prevent 
the  development  of  the  meteorism.  We  shall  see  presently  how  this  pheno- 
menon is  modified  under  the  influence  of  a treatment  entirely  different  from  the 
antiphlogistic. 

The  febrile  movement  was  stopped  after  bloodletting  in  only  a very  small 
number  of  our  patients.  In  others  the  fever  was  only  diminished  after  bleed- 
ing ; whilst  in  some  it  only  became  more  intense  after  this  mode  of  treatment. 
What  was  principally  observed  in  several  instances,  was  the  increased  accelera- 
tion of  the  pulse,  according  as  the  bleeding  was  repeated,  or  immediately  after 
a single  bleeding  was  employed.  But  in  the  great  majority  of  febrile  move- 
ment did  not,  after  bleeding,  undergo  any  immediate  modification,  which  could 
be  attributed  to  it.  It  continued  as  before  ; then,  without  having  appeared  in 
any  way  directly  influenced  by  the  bleeding,  it  gradually  either  increased  or 
diminished. 

The  nervous  symptoms  presented  by  our  patients  were  often  met  by  blood- 
letting, the  employment  of  which  was  far  from  being  invariably  attended  with 
favourable  results,  as  we  shall  see. 

These  symptoms  were  not  diminished  after  bleeding,  more  or  less  frequently 
repeated  in  seven  of  our  cases.  They  were  improved  in  five  instances,  and  in 
fifteen  cases  they  were  rendered  much  worse.  Thus,  in  twenty-seven  indi- 
viduals who  were  bled  during  the  existence  of  these  different  disturbances  of 
innervation,  there  were  only  five  in  whom  the  nervous  disturbances  were  dimi- 
nished. In  seven  cases  these  disturbances  did  not  appear  to  be  influenced  in 
18 


206 


ANDRAL’S  MEDICAL  CLINIC. 


any  way  by  the  bleeding  ; and  in  fifteen  everything  became  worse  after  the 
patients  lost  blood. 

If  we  would  go  beyond  the  circle  of  the  particular  facts  contained  in  this 
work,  we  would  say  that,  in  many  other  similar  cases  wherein  we  also  tried  to 
combat  the  nervous  symptoms  of  bad  fevers  by  bloodletting,  we  arrived  at  the 
same  results  ; and  we  have  seen  these  symptoms  sometimes  yield  to  bleeding, 
but  most  frequently  resist  it;  sometimes,  also,  become  visibly  worse  after  each 
bleeding.  Such  facts  have  so  frequently  fallen  under  our  observation,  that  we 
are  firmly  convinced  that  repeated  bleeding  not  only  will  not  cause  the  nervous 
symptoms  of  bad  fevers  to  disappear,  but  that  they  occasionally  exercise  a 
direct  influence  on  the  exasperation  of  these  symptoms.  And  observe,  that  this 
exasperation  takes  place  not  only  in  those  cases  where  the  individuals  are  in  a 
state  of  prostration  and  stupor,  where,  in  a word,  the  adynamic  state  predomi- 
nates ; this  exasperation,  after  bleeding,  is  equally  observable  in  several  indi- 
viduals whose  strength  is  far  from  appearing  to  be  exhausted,  who  manifest 
symptoms  of  delirium,  the  different  aberrations  of  sensation  and  motion,  and  in 
whom,  in  a word,  the  ataxic  state  predominates. 

It  appeared  to  us,  also,  that  in  almost  all  cases,  when  no  amendment  is  ob- 
tained, or  when  the  nervous  symptoms  increase  after  the  two  first  bleedings,  it 
is  dangerous  to  repeat  the  operation. 

But  this  is  not  all.  This  part  of  the  work  contains  a number  of  cases  in 
which  the  nervous  symptoms  developed  themselves  immediately  after  the 
patients  were  bled.  See  Cases  1,  4,  13,  17,  19,  20,  68,  69,  72. 

From  these  latter  facts,  we  shall  merely  draw  the  conclusion  that  bleeding, 
employed  at  a period  when  the  innervation  as  yet  presents  no  disturbance,  does 
not  prevent  this  function  from  being  subsequently  disturbed  ? Shall  not  these 
facts  induce  us  to  inquire  whether,  in  certain  cases,  the  loss  of  blood  which  the 
patients  sustains  is  not  the  direct  and  immediate  cause  of  the  disturbances  of  the 
innervation  which  he  manifests  ? What  we  have  seen  in  this  respect  scarcely 
allows  us  to  doubt  but  that  this  is  sometimes  the  case.  But,  to  solve  this  question 
satisfactorily,  how  many  facts  are  not  still  wanting  ! 

There  are,  moreover,  many  other  phenomena  connected  with  bad  fevers,  in 
reference  to  which  the  questions  just  proposed  may  be  again  started.  What 
influences,  for  instance,  has  bloodletting  on  epistaxis,  which  appears  so  often 
in  different  stages  of  these  diseases?  By  reference  to  our  cases,  we  shall  find 
some  in  which  nasal  hemorrhage  came  on  after  bleeding.  We  find  other  cases, 
also,  in  which,  notwithstanding  bleeding  was  resorted  to,  the  attacks  of  epistaxis 
became  more  and  more  frequent,  according  as  a vein  was  opened,  or  leeches 
were  applied. 

After  epistaxis,  we  shall  consider  the  phenomenon  of  petechia  with  respect 
to  the  influence  of  bloodletting  on  those  small  cutaneous  hemorrhages.  In 
several  cases  these  hemorrhages  came  on  after  bleeding.  In  no  instance  did 
bleeding  appear  to  contribute  to  their  disappearance.  We  have  already  men- 
tioned a fact  which  proves  beyond  doubt  the  influence  which  excessive  loss  of 
blood  exercises  on  the  production  of  petechiae.  We  may  remark,  that  we  have 
seen  them  cover  the  skin  with  almost  equal  frequency,  both  in  those  who  had 
been  and  in  those  who  had  not  been  bled. 


SECTION  III. 

TREATMENT  BY  EVACUANTS. 

Forty-six  of  our  patients  were  subjected  to  this  mode  of  treatment ; ten  took 
only  purgatives,  and  thirty-six  took  nineties,  generally  uncombined  ; sometimes, 
however,  in  combination  with  cathartics. 


DISEASES  OF  THE  ABDOMEN. 


207 


In  the  ten  individuals  who  were  only  purged  the  following  results  were  ob- 
served : — Only  one  of  them  found  any  beneficial  effect,  but  this  individual  was 
placed  under  particular  circumstances.  The  cause  of  the  fever,  and  of  the  other 
bad  symptoms  in  this  case,  was  attributable  to  an  accumulation  of  faeces  of  long 
standing,  and  a cure  was  effected  by  removing  these. 

In  four  other  cases  the  purgatives  employed,  whether  at  the  onset  of  the  dis- 
ease or  during  its  progress,  did  not  curtail  its  course  ; neither  did  they  appear 
to  exercise  over  it  a directly  injurious  influence.  However,  in  these  four  cases 
the  disease  terminated  fatally. 

In  five  other  cases  the  employment  of  purgatives,  given  by  the  mouth  or  in 
the  form  of  lavement,  was  followed  by  a more  or  less  immediate  exasperation 
of  the  symptoms.  The  individual  in  question  took  a great  number  of  laxatives 
during  the  course  of  the  disease.  In  these  five  individuals  the  affection  termi- 
nated fatally. 

Of  thirty-six  patients  who  took  emetics,  three  experienced  no  perceptible 
effects  from  them  ; eleven  found  them  injurious,  either  immediately,  or  after  an 
improvement  which  was  but  transitory.  Twenty-two  recovered  rapidly  after 
having  taken  tartar  emetic  or  ipecacuanha. 

In  the  majority  of  cases  of  this  third  class,  the  change  for  the  better  which 
followed  the  employment  of  the  emetic  was  so  prompt  and  so  marked,  that  it 
is  impossible  to  refuse  to  allow  that  the  treatment  had  an  active  share  in  the  cure. 
But  we  should  be  cautious  in  supposing  that  it  was  in  as  great  a proportion  as 
the  recoveries  which  took  place  after  emetics^  This  proportion  is  found  so 
considerable  in  our  cases  only  because,  as  we  wished  to  prove  that  these  emetics 
are  not  only  oftentimes  unattended  with  danger,  but  that  their  efficacy  is  at  times 
very  great,  we  are  obliged  to  select,  amidst  a great  number  of  facts,  those  whose 
efficacy  might  be  least  disputed.  Had  we  published  all  the  cases  which  we  have 
met  with  in  which  emetics  were  given,  we  should  have  found  a considerable 
number  wherein  we  should  have  seen  the  disease  no  more  influenced  by  emetics 
than  it  was  in  other  cases  by  bloodletting.  We  might  also  have  found  a greater 
number  than  that  cited  by  us  in  which  the  employment  of  emetics  was  very 
injurious. 

From  the  results  of  the  cases  contained  in  this  volume,  we  should  not  then 
infer  that  the  treatment  by  emetics  was  more  successful  than  other  modes  of 
treatment.  But  the  consequence  to  be  drawn  is  this,  that  emetics  may  be  given 
with  impunity  in  some  cases,  and  that,  in  others,  they  are  followed  by  an  im- 
provement which  we  had  to  no  purpose  endeavoured  to  obtain,  either  by  the 
simple  expectant  method,  or  even  by  bloodletting.  What  are  now  the  cases  in 
which  it  is  right  to  have  recourse  to  emetics  ? This  will  be  shown  to  us  by 
the  examination  of  the  influence  of  these  medicines  over  the  principal  symptoms 
of  fever. 

There  are  few  functional  disturbances  of  the  digestive  passages  which  we  have 
not  seen  to  disappear  promptly  after  the  employment  of  an  emetic. 

Thus  the  loss  of  appetite  and  bad  taste  in  the  mouth  ceased  after  vomiting 
was  excited  in  several  of  our  patients. 

The  nausea  and  vomiting  which  annoyed  some  of  our  patients  did  not  appear 
after  they  took  an  emetic. 

After  the  employment  of  these  same  means,  we  saw  the  pain  in  the  epigas- 
trium, and  the  constriction  or  weight  in  the  same  region,  disappear  in  some  of 
our  cases. 

Some  of  our  patients,  to  the  number  of  twenty-five,  had  their  tongue  covered 
with  a white  or  yellow  coat,  more  or  less  thick,  without  the  admixture  of  any 
redness,  without  any  contraction  of  its  muscular  tissue,  its  moist  appearance  still 
remaining,  when  they  took  a simple  emetic,  or  an  emeto-cathartic.. 

In  only  two  of  these  twenty-five  cases  did  the  state  of  the  tongue  become 


208 


ANDliAL’S  MEDICAL  CLINIC. 


worse  after  the  emetic  ; it  became  red  and  dry.  In  six  of  these  same  patients 
the  tongue  remained  what  it  was  before  vomiting  had  been  excited.  In  the  re- 
maining seventeen  the  tongue  resumed  its  natural  appearance  in  twenty-four  or 
thirty-six  hours. 

In  one  case,  in  which  the  tongue  was  covered  with  a uniform  whitish  coat, 
as  in  the  preceding,  and  also  presented  an  appearance  of  commencing  dryness, 
an  emetic  was  given,  and  the  tongue  rapidly  returned  to  its  normal  state. 

Instead  of  being  white  or  yellow,  without  any  mixture  of  redness,  the  tongue 
presented  either  uniform  redness,  without  any  coat,  or  a red  tint  at  the  apex, 
edges,  or  centre,  with  a coat  on  the  other  parts,  or  else  a cluster  of  red  points 
over  its  entire  surface,  as  was  observed  in  ten  of  our  cases.  Notwithstanding 
such  a state  of  the  tongue,  these  ten  patients  were  treated  with  emetics. 

In  four  of  these  ten  the  tongue  resumed  its  natural  appearance  a little  time 
after  an  emetic  had  been  given,  but  with  circumstances  to  which  it  is  important 
to  revert.  Thus,  in  one  case,  the  tongue  presented  a white  appearance,  with 
red  points,  and  was  beginning  to  become  dry  ; the  latter  phenomenon  disap- 
peared after  a bleeding  : it  was  then  an  emetic  was  given,  which  purged  without 
vomiting.  In  another  of  these  four  cases,  to  be  sure,  the  tongue  lost  some  of 
its  redness  after  the  patient  had  vomited  ; but  every  other  symptom  became 
worse.  In  another  of  these  four  patients,  whose  tongue  presented  two  white 
lateral  bands,  with  a red  appearance  of  its  centre,  this  tongue  did  not  resume 
its  natural  appearance  till  a profuse  perspiration  was  brought  on  by  vomiting 
with  six  grains  of  ipecacuanha. 

In  three  of  those  ten  cases  the  tongue  underwent  no  change  after  the  adminis- 
tration of  an  emetic.  Again,  in  the  three  others  the  tongue  became  redder,  or 
was  even  dry,  after  an  emetic  was  taken. 

Diarrhoea,  of  greater  or  less  severity,  affected  sixteen  individuals  when  an 
emetic  was  given  to  them.  In  only  two  of  these  sixteen  persons  the  diarrhoea 
was  not  modified. 

In  the  other  fourteen  it  was  suspended  ; but  this  suspension  did  not  always 
occur  in  the  same  way  ; sometimes  the  diarrhoea  ceased  abruptly,  and  did  not 
reappear;  and  sometimes  it  continued  for  twenty  or  thirty  hours,  and  then 
ceased.  In  several  instances  it  appeared  more  profuse  on  the  day  the  emetic 
was  given,  and  the  following  day  it  disappeared.  At  other  times,  after  having 
ceased  immediately  after  vomiting  had  been  excited,  it  reappeared  on  the  next 
day,  or  the  day  after  that;  this  reappearance,  however,  was  but  temporary. 
At  other  times,  after  being  suspended  for  the  thirty  or  forty  hours  following  the 
vomiting,  it  reappeared,  and  continued. 

In  four  of  our  cases  the  diarrhoea  appeared  after  the  employment  of  an 
emetic.  After  having  existed  at  the  commencement  of  the  disease,  and  then 
ceased  spontaneously,  it  appeared  again  after  the  employment  of  the  same 
medicine  in  two  of  our  cases. 

Much  importance  has  been  attached,  in  latter  times,  to  those  cases  in  which 
the  functional  disturbances  of  the  stomach  come  to  be  complicated  with  fever 
after  the  administration  of  an  emetic  ; but,  prejudiced  as  persons  were  with 
respect  to  the  injurious  effects  of  emetics,  they  overlooked  other  remarkable 
cases  in  which  this  fever  disappeared,  on  the  contrary,  after  a vomit.  This, 
however,  we  witnessed  in  several  of  our  cases.  Among  the  subjects  of  these 
cases  some  had  profuse  sweats  after  having  vomited,  whilst  some  did  not  sweat. 
In  all  the  fever  ceased  the  very  day,  or  the  day  after,  the  emetic  was  taken. 

In  connexion  with  these  cases,  which  point  out  the  beneficial  influence  of  an 
emetic  over  fever,  we  could  refer  to  others  in  which  the  fever  continued  or  in- 
creased after  vomiting  had  been  excited.  In  some  of  these  cases  there  was  at 
first  an  apparent  amendment  on  the  very  day  when  the  emetic  was  given  ; but 
the  next  day  the  fever  resumed  all  its  intensity.  In  one  of  our  cases  it  was 


DISEASES  OF  THE  ABDOMEN. 


209 


after  the  administration  of  two  grains  of  tartar  emetic  that  exacerbations  appeared 
resembling  those  of  pernicious  fever. 

Whenever  severe  nervous  symptoms  existed,  we  did  not  find  them  to  be 
improved  by  the  employment  of  emetics  or  purgatives.  Sometimes  they 
merely  continued,  sometimes  they  increased  immediately  after  the  use  of  these 
means. 

From  the  different  facts  now  stated,  what  conclusion  shall  we  deduce  ? This 
— that,  notwithstanding  the  strange  abuse  of  evacuants,  their  employment  should 
not  be  generally  proscribed,  and  that  there  are  cases  in  which  their  utility  can- 
not be  called  in  question.  If  there  be  a fact  in  medicine,  of  whichwe  are  con- 
vinced, it  is  the  sudden  improvement  which  occasionally  follows  the  use  of  an 
emetic  or  purgative  in  persons  who  distinctly  present  the  symptoms  of  that  affec- 
tion called  gastric  or  intestinal  derangement  ( embarras ).  Another  fact,  of  which 
we  feel  no  less  convinced,  is,  that  the  fever,  which  may  accompany  these  symp- 
toms, often  disappears  with  the  latter  after  the  patient  has  been  vomited.  To- 
wards the  end  of  the  summer  of  1829,  which  was  occasionally  rather  cold  and 
moist,  we  found  frequentopportunities  of  employing  tartar  emetic  with  the  greatest 
advantage  in  cases  similar  to  those  just  mentioned.  We  shall  confine  ourselves 
to  the  detail  of  the  two  following  cases,  which  bear  considerable  resemblance  to 
others  already  reported. 

A middle-aged  woman  was  received  into  the  hospital  Cochin  during  the  month 
of  September,  1829.  She  complained  of  violent  headach,  of  pain  in  the  joints, 
and  in  different  parts  of  the  chest.  The  countenance  was  expressive  of  great 
prostration,  and  the  red  colour  of  the  cheeks  contrasted  with  the  yellow  tint 
around  the  eyes,  the  alae  nasi,  and  the  lips.  The  tongue  was  covered  with  a thick 
yellow  coat;  the  patient  was  distressed  with  constant  nausea  ; the  epigastrium 
was  free  from  pain  ; the  stools  were  scanty  ; pulse  frequent,  and  skin  hot.  This 
state  continued  for  four  days  ; the  patient  became  weak  ; there  was  a tendency 
to  the  adynamic  state  ; at  this  time  two  grains  of  tartar  emetic  were  given,  and 
she  was  frequently  vomited.  On  the  day  after  we  found  the  patient,  for  the 
first  time,  free  from  fever  ; the  nausea  no  longer  existed  ; the  pains  were  no 
longer  felt ; the  tongue  still  remained  a little  loaded.  On  the  following  days  she 
was  very  well. 

A hotel-keeper  came  under  our  care  with  all  the  symptoms  of  what  is  called 
bilious  fever;  supra-orbital  headach  of  the  most  distressing  character ; pains  of 
the  joints  and  towards  the  loins  ; incessant  inclination  to  vomit,  and  from  time  to 
time  some  vomiting  ; tongue  white,  broad  and  free  from  redness  ; intolerably  bit- 
ter taste  in  the  mouth  ; feeling  of  constriction  at  the  epigastrium  ; constipation  ; 
pulse  frequent  and  hard  i skin  hot,  and  every  evening  a febrile  accession,  during 
which  the  headach  was  very  much  increased  ; the  accession  of  fever  terminated 
every  morning  in  a very  profuse  sweat.  We  had  him  bled  from  the  arm  ; no  im- 
provement followed.  The  application  of  leeches  to  the  anus  was  equally  ineffec- 
tual. Six  days  passed  on  in  this  way,  and  the  state  of  the  patient  was  not  im- 
proved ; the  fever  was  constantly  very  high.  The  patient  stated,  that  some  years 
before  he  had  had  a similar  attack,  and  that  he  got  quite  well  after  being  vomited. 
He  importuned  us  to  try  the  same  means.  We  accordingly  gave  him  two  grains 
of  tartar  emetic.  He  vomited  a great  quantity  of  green  bile.  For  the  rest  of  the 
day  he  no  longer  felt  any  nausea ; in  the  evening  the  febrile  accession  did  not 
return  : in  the  morning  he  was  free  from  fever ; and  the  day  after  was  conva- 
lescent.* 

Experience,  then,  does  not  allow  us  to.  doubt  that,  in  certain  morbid  states, 
with  or  without  fever,  which  are  readily  recognised  by  well-marked  symptoms, 

* We  have,  subsequently  to  this,  met  with  several  other  such  cases,  and  we  feel  satisfied 
that  emeto-cathartics  may  be  given  with  the  greatest  advantage  in  cases  similar  to  the  above. 

IS* 


210 


ANDRAL’S  MEDICAL  CLINIC. 


emetics  may  be  of  real  advantage.  Their  efficacy  in  these  cases  seems  to  us 
one  of  the  strongest  arguments  against  the  doctrine  which  explains  every  func- 
tional disturbance  of  the  stomach  by  gastric  irritation,  and  every  continued  fever 
by  gastro-enteritis.  The  old  theories,  according  to  which  the  success  of  emetics 
was  accounted  for  by  supposing  that  these  agents  freed  the  stomach  from  matter 
accumulated  in  it,  appear  to  us  equally  untenable.  Several  facts  already  men- 
tioned, seem  to  us  clearly  to  prove  that  the  existence  of  these  accumulations  is, 
at  least,  very  hypothetical  ; we  have  found  no  trace  of  such  in  the  stomach  of 
individuals,  who,  up  to  the  moment  of  their  death,  had  presented  that  group  of 
symptoms,  which  Stoll,  for  instance,  would  have  explained  by  the  presence  of 
accumulations  (saburrse)  in  the  stomach. 

Perhaps  we  should  better  appreciate  the  advantages  of  emetics,  if,  instead  of 
considering  only  their  local  action  on  the  stomach,  we  were  to  reflect  on  the 
powerful  impressions  made  by  them  on  several  other  organs,  and  particularly  on 
several  secreting  organs  ; on  the  organs  of  the  circulation  and  respiration,  and 
on  the  nervous  centres.  An  emetic  might  then,  in  our  view  of  the  matter,  serve 
as  a powerful  stimulant,  which,  simultaneously  changing  the  quality  of  several  vital 
acts,  might  produce  in  the  system  a sudden  modification,  which,  according  to  the 
cases  pointed  out  by  experience,  might  itself  prove  salutary  or  injurious. 


SECTION  IV. 

TREATMENT  BY  TONICS  AND  STIMULANTS. 

Forty  of  our  patients  were  put  under  this  treatment.  Quinquina  in  every  form  ; 
wine,  camphor,  musk,  assafeetida,  acetate  of  ammonia,  aether,  different  aromaticr 
distilled  waters,  were  the  different  substances  given  to  them.  Several  of  them 
also  had  some  beef-tea  every  day. 

Of  these  forty  patients  so  treated,  there  were  twenty-six  in  whom  the  disease 
became  worse,  and  terminated  fatally.  Among  these  patients  there  were  some 
in  whom,  during  the  first  days  on  which  tonics  were  employed,  an  improvement 
was  observed,  which  was,  however,  but  temporary. 

With  respect  to  the  other  fourteen,  their  state  was  improved  after  they  com- 
menced the  use  of  tonics  ; and  the  disease  terminated  favourably.  But  with 
reference  to  the  share  which  the  stimulant  treatment  might  have  on  the  cure, 
these  fourteen  persons  must  be  divided  into  two  classes  : in  the  first  we  shall 
place  those  in  whom  a rapid  improvement  was  observed  from  the  time  that 
tonics  were  given.  Under  the  second  class  we  include  those  who,  very  differ- 
ent from  the  former,  experienced  an  improvement  only  gradually,  as  if  the 
simple  expectant  method  had  been  adopted.  If  it  be  admitted  that  the  indivi- 
duals of  the  first  class  owed  the  improvement  which  they  felt  to  tonics,  there 
can  be  no  longer  any  doubt  with  respect  to  the  individuals  of  the  second  class. 

Thus  in  forty  persons  treated  by  tonics,  we  find  twenty-six  in  whom  the  dis- 
ease became  worse,  during  the  employment  of  these  medicines  ; eleven  on  the 
contrary,  in  whom  it  was  improved  during  the  use  of  these  same  tonics,  and  only 
three  in  whom  the  improvement  followed  so  closely  on  the  commencement  of 
the  use  of  stimulants,  that  it  seems  reasonable  to  conclude  that  it  was  to  this 
treatment  the  amendment  was  owing. 

In  the  individuals  treated  with  tonics,  the  different  functional  disturbances  are 
in  general  aggravated,  or  improved,  according  as  the  disease  itself  is  so  modi- 
fied. Thus  with  respect  to  the  febrile  disturbance,  and  nervous  symptoms,  we 
would  only  repeat  what  has  been  already  stated  in  the  preceding  paragraphs. 

The  tongue  returned  to  its  natural  state  during  the  employment  of  tonics,  in 


DISEASES  OF  THE  ABDOMEN. 


211 


nine  of  our  patients.  This  return  was  rapid  in  some  ; slow  and  progressive  in 
the  greater  number.  Whilst  presenting  its  natural  appearance,  when  we  began 
to  give  tonics,  it  continued  to  present  this  appearance  during  their  employment 
in  four  cases. 

It  became  dry,  red  or  black  during  the  use  of  quinquina,  and  other  tonics,  or 
stimulant  medicines,  in  fifteen  patients.  It  presented  remarkable  alternations 
of  dryness  and  moisture,  of  redness  and  paleness,  in  three  other  individuals. 
Dry,  red,  brown,  or  black,  when  tonics  began  to  be  given;  it  continued  so  in 
nine  of  the  patients  placed  under  our  care.  During  the  use  of  tonics,  the  diar- 
rhoea ceased  in  three  cases ; it  continued  in  seventeen,  and  came  on  in  four 
cases. 

During  this  same  treatment  meteorism  ceased  in  five  cases,  it  increased  very 
much  in  one  instance,  and  it  continued  in  five  cases,  and  made  its  appearance 
in  three  other  cases,  at  the  same  time  that  the  patients  were  submitted  to  a sti- 
mulant treatment. 

We  do  not  pretend  to  say  that  the  recapitulation  just  given,  accurately  repre- 
sents the  opinion  of  medical  men,  with  respect  to  the  degree  of  advantage  to 
be  derived  from  tonics  in  the  diseases  treated  of  in  this  part  of  the  work;  we 
are  only  desirous  that  our  observation  should  invite  the  attention  of  practition- 
ers, and  induce  them  to  make  new  researches  in  reference  to  this  subject : for 
we  do  not  consider  such  a question  finally  settled  ; and  certainly  it  is  not  by 
the  mere  data  of  pathological  anatomy,  that  we  can  expect  to  solve  it.  Thus 
we  see  in  another  part  of  this  work  pneumonia  treated  with  stimulants.  Here 
it  is  no  longer,  from  the  sole  consideration  of  the  local  lesion,  that  the  indica- 
tions are  derived  ; the  same  may  be  said  of  a great  number  of  other  cases. 
Whatever  importance,  then,  we  may  have  attached,  in  fevers , to  inflammation 
of  the  digestive  passages,  we  cannot  admit,  that,  in  all  cases,  therapeutics  should 
be  entirely  subordinate  to  this  inflammation.  This  view  of  the  matter  was 
taken  up,  several  years  since,  by  M.  Bouillaud,  when,  whilst  he  laid  it  down 
as  certain,  that  the  majority  of  what  are  called  adynamic  fevers,  had  their  origin 
in  an  inflammatory  state  of  the  intestine,  he  advised  the  employment  of  chlo- 
rurets,  to  combat  the  consecutive  changes  which  he  admitted  to  exist  in  the 
blood.  We  have  several  times  employed  these  chlorurets  of  late,  and  we  must 
say  that,  in  more  than  one  case  of  bad  typhoid  fever,  their  employment  has 
coincided,  in  the  most  striking  manner,  with  a general  improvement  of  the 
symptoms,  and  has  been  attended  with  the  recovery  of  the  patient.* 


SECTION  II. 

DISEASES  OF  THE  DIGESTIVE  TUBE,  IN  WHICH  THE  LOCAL  SYMPTOMS 
EXIST  WITHOUT  ANY  OTHER  SYMPTOMS,  OR  IN  WHICH  THEY  WERE 
PREDOMINANT. 

The  cases  reported  in  the  first  section  presented  to  us  several  forms  of  gas- 
trointestinal inflammations,  in  which  the  general  symptoms,  either  by  their 
number  or  intensity,  influence  very  much  the  local  symptoms.  In  the  present 

* The  way  in  which  we  administered  the  chlorurets  is  as  follows : we  gave  in  each  pot  of 
ptisan  from  fifteen  to  twenty  drops  of  chloruret  of  soda;  we  put  half  of  this  quantity  into  the 
draughts  ; we  also  gave  from  twenty-eight  to  thirty  drops  in  the  form  of  lavement ; and  we 
sprinkled  this  same  liquid  over  the  cataplasms  with  which  we  covered  the  abdomen.  This  is 
also  the  way  in  which  the  chlorurets  have  been  administered  by  Professor  Chomel,  who  was 
one  of  the  first  to  employ  them  in  the  treatment  of  typhoid  fevers. 


212 


ANDRAL’S  MEDICAL  CLINIC. 


section  this  will  no  longer  be  so,  and  the  cases  which  it  contains  are  such 
that  the  seat  of  the  disease  is  readily  and  clearly  indicated  by  the  seat  of  the 
symptoms. 


CHAPTER  I. 

OBSERVATIONS  ON  ACUTE  GASTRITIS. 

For  some  years  after  the  publication  of  M.  Broussais’s  work  on  inflammation 
of  the  digestive  passages,  acute  gastritis  was  considered  by  many  physicians 
as  a very  common  affection,  and  a number  of  acute  diseases,  widely  differing 
from  one  another,  were  referred  to  it.  However,  more  exact  observation  soon 
pointed  out  that  acute  inflammation  of  the  stomach  was  not  an  affection  so  fre- 
quently met,  and  that  in  many  cases  its  existence  had  been  supposed  gratui- 
tously. This  was  the  truth  : but  men  did  not  keep  to  it  — a reaction  in  a con- 
trary direction  soon  took  place  ; and  some  medical  men  went  so  far  as  to  say, 
that  acute  gastritis,  with  the  exception  of  that  produced  by  corrosive  poisons, 
was  an  inflammation  so  uncommon,  that  they  had  not  as  yet  met  with  a single 
instance  of  it.  However,  in  the  former  part  of  this  work  we  have  cited  some 
cases  in  which  the  febrile  disturbance  and  the  symptoms  of  reaction  towards 
the  brain  could  be  explained  only  by  the  inflammation,  of  which  very  evident 
traces  were  found  in  the  stomach.  The  following  cases,  whilst  they  will 
further  prove  the  real  existence  of  this  inflammation,  will  afford  us  an  opportu- 
nity of  studying  it  in  its  most  important  forms. 

Case  1. — Vomiting;  pain  in  the  epigastrium;  tongue  at  first  white,  then  red  and  dry,  and 
afterwards  covered  with  aphthous  eruption — Continued  fever — Death  after  thirty  days’  ill- 
ness— Gastric  mucous  membrane  red  and  friable. 

A woman,  twenty-seven  years  of  age,  who  had  always  enjoyed  good  health, 
suffered  in  the  commencement  of  November,  1830,  some  domestic  annoyances. 
From  this  time  her  digestion,  which  till  then  was  good,  became  disturbed  ; she 
felt  an  acute  pain  in  the  epigastrium,  and  soon  after  every  thing  she  swallowed 
was  rejected.  Five  days  passed  on  this  way;  after  this  she  took  to  bed,  and 
then  entered  the  Maison  Royale  de  Sante.  The  following  was  her  state  at  this 
time  : — 

Her  countenance,  which  was  generally  pale,  presented  on  each  cheek  a deep 
red  patch  ; a black  circle  surrounded  her  eyes  ; she  was  very  feeble,  and  spoke 
with  a very  faint  voice.  Within  the  last  twenty-four  hours  she  had  vomited 
several  times  nearly  a pint  of  bilious  matter,  which,  during  its  passage,  was  in- 
tolerably bitter.  All  the  drinks  which  she  strove  to  take  were  immediately  re- 
jected. She  constantly  applied  the  hand  to  the  epigastrium,  and  complained  of 
a very  acute  pain  in  this  part ; the  remainder  of  the  abdomen  was  free  from 
pain.  There  had  been  no  stools  for  the  last  four  days  ; the  tongue  was  covered 
with  a white  coat,  presenting  beneath  it  a great  number  of  red  points,  most  ap- 
parent towards  the  anterior  extremity  of  the  organ.  The  patient  complained 
of  being  tormented  with  severe  thirst,  which  she  did  not  venture  to  satisfy  ; 
the  distress  which  accompanied  each  vomiting  made  her  dread  very  much 
the  return  of  it.  The  pulse  was  more  than  U2  per  minute,  and  in  the  same 
space  of  time  twenty-eight  respirations  were  counted.  The  skin  was  hot 
and  dry. 

We  considered  this  woman  as  labouring  under  acute  inflammation  of  the  sto- 
mach. We  directed  forty  leeches  to  be  applied  over  the  epigastrium,  the  bleeding 
of  which  was  encouraged  by  means  of  a warm  bath.  A weak  infusion  of  mal- 
low flowers  was  the  only  drink  allowed. 


DISEASES  OF  THE  ABDOMEN. 


213 


On  the  following  day  there  were  some  amendment;  the  vomiting  had  not 
ceased,  but  it  was  less  frequent  and  less  copious  ; the  patient  had  been  able  to 
retain  a little  of  the  drink  what  she  had  taken ; she  suffered  less  in  the  pit  of 
the  stomach  ; still  the  fever  continued. 

During  the  eight  hours  following  the  state  of  the  patient  became  alternately 
better  and  worse.  But  she  never  passed  twenty-four  hours  without  vomiting, 
sometimes  bile,  sometimes  whitish  mucus  ; occasionally,  after  efforts  which 
lasted  for  more  than  half  an  hour,  she  threw  up  nothing  but  a liquid  resembling 
white  of  egg.  The  pulse  retained  its  frequency,  and  the  epigastric  pain  always 
continued  with  variable  intensity ; the  tongue  retained  the  same  appearance. 
We  scarcely  had  been  able  to  obtain  a single  stool,  during  all  this  time,  by 
repeated  lavements.  Thirty  leeches  were  a second  time  applied  to  the  epigas- 
trium, and  several  baths  were  given.  After  this  time  we  tried  the  use  of  ice, 
but  she  could  not  bear  it ; Seltzer  water,  mixed  with  gum  water,  was  not  more 
successful;  we  were  also  obliged  to  give  up  different  aromatic  infusions,  which 
we  tried  ; she  soon  refused  every  thing,  and  would  not  consent  to  take  any 
liquid  but  a little  cold  water,  that  seemed  to  agree  best  with  her. 

Still  the  state  of  debility  went  on  increasing  : she  wasted  away  with  frightful 
rapidity  ; towards  the  twentieth  day  the  skin  ceased  to  feel  hot,  but  the  pulse 
still  retained  its  frequency.  Towards  this  period  we  applied  to  the  epigastrium 
a blister,  on  the  surface  of  which  we  put  some  hydrochlorate  of  morphine. 
The  vomiting  underwent  no  change  from  this  application.  Towards  the 
twenty-sixth  day  the  tongue  lost  the  white  coat  with  which  it  was  covered,  it 
became  red  and  smooth  over  its  entire  surface.  Towards  the  thirty-fourth  day 
the  tongue  began  to  become  covered  with  small  white  points,  which  soon  be- 
come visible  also  on  the  inner  surface  of  the  cheeks  and  gums.  These  points, 
increasing  in  number,  soon  became  converted  into  broad  patches,  which  covered 
the  tongue,  like  a confluent  aphthous  eruption,  as  also  the  inside  of  the  month 
and  the  velum  palati.  The  patient  died  towards  the  fortieth  day.  The  vomit- 
ing had  ceased  three  or  four  days  before  death. 

Post-mortem. — Beneath  the  whitish  layer  which  covered  the  tongue  and 
cheeks,  the  mucous  membrane  of  these  parts  was  intensely  red.  The  pharynx 
and  oesophagus  were  in  a healthy  state.  The  stomach,  which  was  strongly 
contracted,  was  nearly  the  size  of  the  transverse  colon.  Its  inner  surface,  over 
nearly  its  entire  extent,  was  of  a brownish  red.  This  colour  had  its  exclusive 
seat  in  the  mucous  membrane,  which  had  become  in  every  part  very  thick,  and 
was  at  the  same  time  very  friable.  On  its  free  surface  there  was  discovered  a 
multitude  of  small  red  or  blackish  points,  which  seemed  to  have  their  principal 
seat  in  the  villi ; however,  beneath  these  the  body  of  the  mucous  membrane 
was  red,  and  as  it  were  penetrated  with  blood ; in  no  part  cotild  this  membrane 
be  detached,  it  gave  way  under  the  forceps,  and  in  several  points  it  resembled 
a pulp  without  any  consistence.  Such  was  the  state  of  the  mucous  membrane 
of  nearly  the  entire  stomach,  except  near  the  pylorus,  where  it  resumed  its 
normal  consistence,  and  where  its  colour  was  merely  greyish.  The  remainder 
of  the  digestive  tube  was  pale  ; neither  patches  nor  isolated  follicles  were  dis- 
covered in  it. 

The  other  organs  presented  nothing  remarkable. 

Here  is  a case  wherein  acute  inflammation  of  the  stomach  presented  itself  free 
from  any  complication  ; and  wherein,  consequently,  all  the  symptoms  observed 
during  life  must  be  referred  to  it. 

These  symptoms  were  very  marked  ; they  pointed  out,  beyond  all  manner  of 
doubt,  both  the  seat  and  nature  of  the  disease.  During  its  continuance  the  cir- 
culation was  disturbed  ; but  that  was  the  only  sympathetic  phenomenon  which 
occurred ; at  first  there  was  acceleration  of  the  pulse  and  heat  of  skin,  at  one 
and  the  same  time  ; but  at  a later  period,  according  as  the  general  debility  in- 


214 


ANDIiAL’S  MEDICAL  CLINIC. 


creased,  the  skin  returned  to  its  ordinary  temperature,  and  the  disturbance  of 
the  circulation  was  no  longer  announced  except  by  the  frequency  of  the  pulse. 
Here  the  febrile  disturbance  was  evidently  dependent  on  the  morbid  process 
going  on  in  the  stomach. 

The  different  appearances  presented  by  the  tongue  during  the  progress  of  the 
disease  are  deserving  of  attention.  The  thick  white  coat  which  covered  it  at 
first,  might  have  made  one  mistake  the  real  nature  of  the  affection;  but  beneath 
this  coat  the  tongue  was  intensely  red  ; it  was  far  from  being  pale  at  its  circum- 
ference, and  this  was  not  one  of  those  cases  where  the  white  coating  of  the 
tongue  could  be  combated  by  an  emetic.  However,  according  as  the  disease 
progressed,  the  tongue  threw  off  the  coat  which  covered  it,  and  assumed  a 
uniform  red  appearance.  At  a later  period,  again,  it  was  attacked  by  an  erup- 
tion, resembling  that  of  aphthae  ( muguet ),  and  that  was  the  prelude  to  the  fatal 
termination.  Thus,  the  different  changes  which  the  tongue  underwent  were 
directly  proportioned  to  the  constantly  increasing  severity  of  the  disease  ; and 
however  different  the  appearances  were  which  this  organ  presented  at  different 
periods,  they  were  all  connected  with  an  inflammatory  state  of  the  stomach. 

We  seldom  see  vomiting  continue  so  long,  and  in  so  uniform  a manner,  as  in 
this  case.  All  the  therapeutic  means  opposed  to  it  were  of  no  avail ; they  were 
not  more  effectual  against  this  symptom,  than  against  the  disease  itself  which 
progressed  and  increased  without  ceasing,  notwithstanding  the  active  antiphlo- 
gistic treatment  employed  from  its  very  first  appearance. 

Case  2. — Vomiting;  tongue  red  and  dry  ; pain  of  epigastrium — Fever — Three  weeks’  illness — 
Redness  and  softening  of  the  mucous  membrane  of  the  stomach. 

A woman,  seventy-four  years  of  age,  entered  the  Pitie,  October  25,  1832. 
Some  days  before  her  admission  this  woman  had  been  seized  with  an  acute  pain 
in  the  pit  of  the  stomach,  and  with  vomiting.  These  symptoms  came  on  without 
any  known  cause.  When  we  saw  her  she  was  very  weak.  The  tongue  pre- 
sented a uniform  red  colour,  and  it  was  very  smooth  on  its  surface.  The 
patient,  who  was  distressed  with  intense  thirst,  vomited  all  the  drink  she  took; 
she  complained  of  an  intense  pain  in  the  epigastrium,  which  was  increased  by 
pressure  ; the  rest  of  the  abdomen  was  free  from  pain,  and  not  tympanitic ; no 
stool  had  taken  place  within  the  last  three  days  ; there  was  a slight  cough ; 
pulse  was  frequent,  and  skin  hot.  Twenty-five  leeches  were  applied  to  the  pit 
of  the  stomach.  Gum  water  was  ordered  her. 

During  the  following  days  the  vomiting  still  continued ; not  only  her  drink 
was  rejected,  but  occasionally  she  vomited,  from  time  to  time,  with  great  effort 
and  considerable  distress,  a small  quantity  of  bile,  sometimes  yellow,  and  some- 
times green.  The  vomiting  of  this  bile  was  preceded  by  a sensation  of  burning 
at  the  xiphoid  cartilage,  and  at  the  time  when  it  was  vomited  the  same  sensa- 
tion extended  all  along  the  cesophagus.  The  pulse,  which  was  accelerated  from 
the  commencement,  continually  became  smaller;  emaciation  and  debility  made 
rapid  progress,  and  she  died  on  the  11th  of  November,  without  presenting 
any  new  symptom.  For  the  last  few  days  before  death,  the  tongue,  which 
was  intensely  red,  became  very  dry  ; the  nausea  and  vomiting  continued  to  the 
very  last. 

Post-mortem. — Nothing  remarkable  in  the  pharynx  or  cesophagus.  The 
stomach  was  strongly  contracted,  particularly  towards  the  pyloric  portion.  A 
viscid,  thready  mucus,  of  a yellowish  white  colour,  and  very  adherent  to  its 
parietes,  lined  its  inner  surface.  Beneath  this  mucus,  which  was  not  removed 
without  some  difficulty,  we  found  the  mucous  membrane,  of  a dark  red  colour, 
over  the  entire  surface  of  the  great  cul-de-sac,  and  over  all  the  posterior  surface 
from  the  cardia  to  the  pylorus.  This  redness  penetrated  the  entire  substance 
of  the  membrane,  which  had  lost  its  consistence  in  every  part  where  it  was  red  ; 


DISEASES  OF  THE  ABDOMEN. 


215 


in  some  points  it  was  merely  a sort  of  pulp,  which  could  no  longer  be  raised 
with  the  forceps.  Towards  the  anterior  surface  the  mucous  membrane  pre- 
sented a slate-coloured  tint,  without  its  consistence  being  much  changed;  near 
the  pylorus  some  mamillation  was  observed.  The  different  tissues  subjacent 
to  the  mucous  membrane  were  in  the  normal  state,  and  there  was  a striking 
contrast  between  the  perfect  whiteness  of  the  submucous  cellular  tissue,  and  the 
intense  redness  of  the  membrane  which  covered  it.  The  small  intestine  con- 
tained in  its  upper  part  a yellowish  liquid,  which  became  reddish  inferiorly.  It 
presented  a considerable  injection  in  several  points.  The  large  intestine  was 
pale  in  general.  The  liver,  which  was  of  the  ordinary  size,  was  pale,  and 
readily  torn.  The  gall-bladder  was  distended  with  a great  quantity  of  yellow 
bile,  and  in  this  was  a calculus  of  an  oval  form,  crystallized  internally,  the  size 
of  an  almond.  Each  ovary  was  changed  into  a multilocular  tumour,  about  the 
size  of  an  egg.  The  cavity  of  the  uterus  was  filled  with  a reddish  liquid.  Some 
calcareous  concretions,  surrounded  hy  a black  and  indurated  parenchyma,  were 
discovered  in  the  upper  lobe  of  each  lung.  There  were  also  some  ossifications 
of  the  aorta. 

The  only  organ  in  which  we  found  any  alteration  after  death  was  the  stomach, 
and  it  was  also  to  a gastritis  that  we  had  referred  all  the  symptoms  during  life. 
These  were  nearly  the  same  as  in  the  first  case;  the  vomiting  continued  with 
equal  obstinacy,  though  not  so  profuse  ; the  epigastric  pain  was  equally  intense  ; 
the  tongue  was  red  and  dry  from  the  commencement;  it  began  by  becoming 
covered  with  a white  coat,  as  in  the  preceding  case,  but  no  trace  of  aphthae  ap- 
peared towards  the  termination,  as  we  had  observed  in  the  former  instance.  In 
both  the  febrile  disturbance  was  the  same,  and  in  both  patients  death  was 
equally  the  consequence  of  the  progressive  debility  into  which  the  acute  inflam- 
mation of  the  stomach  had  plunged  them.  It  came  on  more  promptly  in  the 
subject  of  the  second  case,  who  was  much  older  than  the  first. 

In  the  following  case  we  shall  again  see  acute  inflammation  terminate  fatally, 
after  having  lasted  from  thirty-six  to  forty  days  ; the  anatomical  lesion  will  still 
be  the  same,  but  there  will  be  some  difference  in  the  symptoms. 

Case  3. — Rheumatic  affection  at  first;  after  some  days,  sudden  disappearance  of  the  articular 

pains,  succeeded  by  intense  pain  in  the  epigastrium — Continuance  of  the  latter,  and  of  fever, 

for  forty  days — Vomiting  only  during  the  first  few  days  ; delirium  towards  the  termination — 

Tongue  at  first  white,  then  red  and  dry,  and  subsequently  diphtherite — Redness  and  soften- 
ing of  the  mucous  membrane  of  the  stomach. 

A woman,  fifty-five  years  of  age,  of  a tolerably  good  constitution,  and  subject 
to  indigestion,  was  in  good  health  when  news  were  brought  to  her  that  one  of 
her  children  had  received  a serious  injury  in  one  of  the  streets  of  Paris.  She 
suppressed  her  grief,  flew  to  its  assistance,  and  for  the  remainder  of  the  day 
did  not  appear  ill;  but  she  could  not  sleep  the  entire  ’night;  and  on  the  next 
morning  she  was  attacked  with  a violent  fit  of  shivering,  which  was  succeeded 
by  burning  heat.  The  latter  continued  for  the  entire  day,  and  towards  night 
several  of  the  joints  became  swollen  and  painful.  Three  or  four  days  passed 
on  in  this  way,  during  which  she  presented  all  the  symptoms  of  acute  articular 
rheumatism,  with  fever.  After  this  time,  and  without  any  active  treatment 
having  been  employed,  the  swelling  and  pain  of  the  joints  ceased  suddenly,  but 
at  the  same  time  the  patient  felt  an  acute  dragging  pain  in  the  pit  of  the  sto- 
mach, for  which  leeches  were  applied  to  the  epigastrium.  The  pain  became 
less,  but  it  did  not  disappear  ; for  the  five  or  six  days  following  the  patient  kept 
to  her  bed,  and  continued  to  suffer  from  the  pain  in  the  stomach.  She  then 
entered  the  Pitie  in  the  beginning  of  February,  1832.  She  was  then  twelve 
days  ill.  She  had  intense  fever,  and  complained  of  pain  in  the  epigastrium, 
which  was  increased  by  pressure  ; had  distressing  thirst,  complete  loss  of  ap- 


216 


ANDRAL’S  MEDICAL  CLINIC. 


petite,  but  neither  nausea  nor  vomiting;  she  had  not  been  more  than  once  or 
twice  at  stool  for  the  last  twelve  days.  The  tongue,  which  was  covered  with 
a thick  white  coat,  presented  at  the  same  time  a number  of  bright  red  points  at 
its  apex  and  edges. 

It  appeared  to  us  that  the  stomach  was  the  original  seat  of  the  fever  and  the 
other  symptoms.  We  ordered  thirty  leeches  to  the  epigastrium  ; they  bled  very 
much.  On  the  next  day,  however,  there  was  no  improvement.  Pulse  120, 
skin  burning  hot,  and  the  epigastric  pain  still  continued.  (Gum  water,  diet, 
lavement  of  marshmallow  water.) 

During  the  twelve  following  days  the  state  of  the  patient  remained  the  same. 
After  this  she  took  a little  broth  and  some  dried  prunes.  On  the  day  after  this, 
light  food  was  given.  We  had  no  reason  to  feel  pleased  at  having  yielded  to 
the  importunities  of  the  patient,  who  pressed  us  to  allow  her  food,  not  that  she 
felt  hungry,  but  because  she  thought  that  food  would  relieve  the  debility,  which 
was  every  day  increasing.  The  tongue,  which  till  then  had  remained  white 
and  moist,  threw  off  the  coat  with  which  it  was  covered  ; it  was  now  become 
red  and  smooth ; the  thirst  was  as  intense  as  on  the  preceding  days,  and  the 
epigastric  pain  was  now  become  more  acute.  The  patient  was  now  so  weak, 
that  at  first  we  hesitated  whether  we  should  recur  to  another  bleeding.  We 
tried  it,  however,  and  twelve  leeches  were  applied  to  the  epigastrium. 

It  did  not  appear  to  us  that  either  good  or  harm  resulted  from  this  measure. 
On  the  day  after  we  found  the  tongue  equally  red  and  dry  ; the  frequency  of 
the  pulse  was  still  the  same.  Nothing  new  was  observed  for  the  three  or  four 
days  following.  At  the  end  of  this  time  another  symptom  appeared  ; the  pa- 
tient began  to  vomit  her  drink,  which  came  up  mixed  with  a small  quantity  of 
yellowish  bile  ; then  the  tongue,  and  all  the  inside  of  the  mouth,  became  covered 
with  white  pellicles,  which  extended  to  the  inner  surface  of  the  cheeks  like 
broad  pseudo-membranes,  between  which  the  mucous  membrane  was  observed 
to  be  red  and  bleeding.  This  diphtheritic  eruption  coincided  with  increased 
debility  ; the  features  were  altered  ; the  pulse  still  continued  frequent ; some 
vomiting  took  place  from  time  to  time  ; wandering  delirium  came  on  ; and 
death  took  place  about  forty-eight  hours  after  her  intellects  began  to  be  disturbed. 
Up  to  the  last  moment  the  stools  were  very  scanty. 

Post-mortem.  Pharynx  and  oesophagus  healthy;  mucous  membrane  of  the 
stomach,  on  its  two  aspects,  of  a bright  red  colour,  and  softened,  and  also  to- 
wards the  great  cul-de-sac;  greyish  mamillary  appearance  of  this  membrane 
towards  the  pylorus  ; slate-coloured  tint  of  the  duodenum,  owing  to  the  black- 
ish colour  of  its  villi ; the  same  tint  was  found  on  the  upper  third  of  the  jejunum. 
Nothing  else  remarkable. 

The  onset  of  this  disease  is  well  deserving  of  attention.  The  strong  mental 
excitement,  which  may  be  considered  as  the  occasional  cause  of  its  develop- 
ment did  not  at  first  act  on  the  stomach  ; articular  rheumatism  declared  itself, 
accompanied  by  intense  fever.  To  judge  from  its  acute  form,  it  was  probable 
that  it  would  be  of  considerable  duration,  and  that  the  tumefied  and  painful 
joints  would  return  but  slowly  to  their  normal  state.  Such,  however,  was  not 
the  case.  All  at  once,  and  before  the  usual  time,  the  rheumatism  completely 
disappeared  ; in  a few  hours  all  the  joints  once  more  became  free,  and  at  the 
same  time,  as  if  by  a sort  of  metastasis,  an  acute  pain  developed  itself  in  the 
stomach,  and  acute  gastritis  took  the  place  of  rheumatism.  But,  very  different 
from  the  disease  which  it  succeeded,  its  course  was  violent,  it  became  more 
and  more  intense.  The  tongue  presented,  during  its  progress,  the  same  changes 
as  those  noticed  in  one  of  the  preceding  cases.  At  first  it  was  covered  with  a 
whitish  coat,  with  red  points  at  its  edges,  then  with  a uniform  red  colour,  and 
ultimately  became  lined  with  false  membranes,  which  gradually  occupied  the 
entire  mouth. 


DISEASES  OF  TIIE  ABDOMEN. 


217 


Whilst  in  the  preceding  cases  the  vomiting  had  been  one  of  the  prevailing 
symptoms,  had  commenced  with  the  disease,  and  had  continued  during  its 
course,  here,  on  the  contrary,  it  was  only  at  the  latter  period,  and  nearly  at  the 
some  time  as  the  diphtherite,  that  the  vomiting  appeared.  This  symptom,  then, 
does  not  necessarily  exist  in  every  acute  inflammation  of  the  stomach,  and  when 
it  does  appear,  it  may,  as  in  the  present  case,  not  accompany  it  in  all  its  course. 
It  is  in  general  a very  bad  sign  when  it  comes  on  at  an  advanced  stage  of  the ' 
disease. 

In  this  case,  as  in  the  two  preceding  cases,  the  epigastrium  was  the  seat  of 
an  acute  pain,  which  continued  during  the  entire  course  of  the  disease.  The 
gastric  mucous  membrane  is  not  then  as  insensible  as  has  been  stated  by  some 
persons.  Still,  in  consequence  of  the  endless  varieties  of  the  sensibility  of  each 
individual,  this  membrane  may  be  inflamed  in  awery  high  degree  without  the 
patient’s  experiencing  any  considerable  pain  in  the  epigastrium.  We  shall 
presently  see  an  instance  of  this.  There  is  no  symptom  necessarily  connected 
with  the  disease  which  it  indicates  in  very  many  cases,  and  there  may  be  acute 
gastritis  without  vomiting  and  without  pain,  as  there  are  instances  of  pleuritis 
without  stitch  in  the  side,  and  pneumonia  without  the  rust-coloured  expecto- 
ration. 

This  was  the  first  time  we  observed  any  delirium,  but  it  came  on  only 
towards  the  termination  of  the  disease,  at  that  period  when  all  the  vital  acts 
become  deteriorated,  when  the  disturbance  of  the  intellect  so  frequently  pre- 
cedes death  by  a few  hours. 

It  may  be  well  to  observe,  that,  up  to  the  time  of  the  disappearance  of  the  arti- 
cular rheumatism,  no  active  treatment  was  employed  ; and  thus  this  affection 
disappeared  altogether  spontaneously,  and  that  in  so  sudden  and  unexpected  a 
manner,  and  passed,  by  a sort  of  metastasis , to  the  stomach. 

We  had  an  opportunity  of  meeting,  in  private  practice,  a case  exactly  simi- 
lar to  that  just  now  reported.  A lady,  about  sixty  years  old,  having  had  all 
her  life  a stomach  the  susceptibility  of  which  rendered  it  imperative  on  her  to 
observe  strict  regimen,  became  very  much  exhausted  in  attending  on  one  of 
her  children  who  was  dangerously  ill.  On  a sudden  she  was  attacked  with 
fever  and  well-marked  articular  rheumatism.  The  delicate  constitution  of  the 
patient,  the  debilitating  causes  which  had  acted  on  her,  the  mental  distress 
which  still  annoyed  her,  induced  us  not  to  abstract  any  blood.  This  rheumatism 
continued  for  some  days,  then  it  disappeared  all  at  once,  and  at  the  same  time 
the  epigastrium  became  painful,  the  tongue  red,  and  the  fever  continued  for  the 
fifty  days  following.  We  observed  precisely  the  same  symptoms  as  those  de- 
tailed in  the  preceding  case,  and  at  the  end  of  this  time  she  died.  The  body 
was  not  examined. 

Case  4. — Severe  cholera — During  convalescence  a reappearance  of  the  vomiting  ; redness  and 
dryness  of  the  tongue  ; acceleration  of  the  pulse ; redness  and  softening  of  the  mucous 
membrane  of  the  stomach. 

A young  man,  twenty-three  years  of  age,  entered  the  Pitie  towards  the  mid- 
dle of  November,  1832,  with  all  the  symptoms  of  violent  cholera;  cyanosis 
existed  to  a very  high  degree,  and  the  pulse  at  the  wrist  could  scarcely  be  felt. 
(Ice  and  Seltzer  water  internally,  narcotics  in  the  form  of  lavement,  rubefa- 
cients to  the  skin.)  Such  were  the  only  means  employed  by  us.  After  being 
forty-eight  hours  in  the  Pitie,  all  the  bad  symptoms  ceased,  and  the  person 
might  be  considered  as  bordering  on  convalescence.  One  day  he  obtained 
more  food  than  we  allowed  ; this  brought  on  a fatal  relapse.  The  day  after 
this  occurrence  we  found  the  patient  in  the  following  state  : — 

The  eyes  were  again  dull  and  sunk  as  when  he  had  cholera  ; the  tongue 
presented  nothing  particular ; he  was  distressed  with  burning  thirst ; he  had 
19 


218 


ANDRAL’S  MEDICAL  CLINIC. 


beside  him  a basin  filled  with  the  matters  which  he  had  vomited ; the  latter 
consisted  in  a great  measure  of  ill-digested  food  ; there  was  no  pain  in  the  epi- 
gastrium, nor  in  the  rest  of  the  abdomen ; some  liquid  stools  had  taken  place. 
The  pulse  was  frequent,  without  the  skin  being  hot.  We  trusted  that  it  would 
be  but  an  attack  of  mere  indigestion,  and  we  waited  till  the  next  day. 

On  the  next  day  the  state  of  the  patient  appeared  more  alarming.  The  vo- 
miting, which  had  continued  all  the  day,  consisted  of  a greenish  bile,  not  con- 
siderable in  quantity  ; the  tongue  was  red  and  dry,  and  still  the  epigastrium 
and  remainder  of  the  abdomen  were  free  from  pain ; neither  were  there  any 
alvine  evacuations.  Pulse  130,  and  the  skin  was  burning  hot.  We  had  no 
doubt  of  the  existence  of  gastritis,  though  the  stomach  was  not  the  seat  of  any 
pain.  We  immediately  prescribed  thirty  leeches  to  the  epigastrium. 

During  the  twenty-five  days  following  the  patient  remained  in  a state  of  con- 
tinued fever,  with  his  tongue  constantly 'red  and  dry.  He  had  burning  thirst, 
frequent  nausea,  and  from  time  to  time  he  vomited  either  a thready  mucus, 
somewhat  resembling  the  'white  of  egg,  or  a yellow  or  greenish  bile.  The 
abdomen,  including  the  epigastrium,  was  free  from  pain  in  all  its  points.  There 
was  obstinate  constipation.  The  patient  arrived  rapidly  at  the  last  stage  of 
marasmus  ; a large  eschar  formed  on  the  sacrum  ; and  he  died,  as  if  exhausted, 
without  a struggle,  and  with  hi-s  intellects  perfect. 

Post-mortem. — The  stomach  was  strongly  contracted  on  itself  over  its  entire 
extent.  It  contained  a small  quantity  of  yellowish  bile,  and  also  a large  lum- 
bricus.  Its  parietes  were  lined  by  a layer  of  whitish  mucus  of  a purulent  ap- 
pearance, and  not  viscid.  Numerous  bands,  which  interlaced  with  each  other, 
appeared  on  its  lower  surface.  The  latter  presented  an  extraordinary  appear- 
ance. On  a brownish  ground  there  appeared  a great  number  of  bright  red  spots, 
which  gave  the  mucous  membrane  a sort  of  spotted  appearance.  These  spots, 
which  were,  on  an  average,  about  the  size  of  a centime,  consisted  of  a group 
of  very  fine  curiously  injected  vessels  ; there  were  sixty  of  these  at  least  scat- 
tered over  the  inner  surface  of  the  stomach.  Where  these  spots  existed  the 
mucous  membrane  was  soft,  and,  as  it  were,  pulpy  ; between  them  it  was  thick- 
ened, and  might  be  raised  in  large  shreds.  The  valvulae  of  the  duodenum  were 
considerably  injected,  as  well  as  those  of  the  commencement  of  the  jejunum. 
On  the  remainder  of  the  small  intestine  we  found  nothing  else  to  notice,  except 
a considerable  number  of  Brunner’s  follicles,  which  were  scattered  over  the 
lower  third.  These  follicles  were  white,  and  not  much  developed.  The  large 
intestine  was  white,  and  contained  some  faeces. 

In  the  other  abdominal  viscera  we  observed  nothing  else  save  a considerable 
enlargement  of  the  spleen,  the  tissue  of  which  was  at  the  same  time  softened, 
and  a greater  friability  of  the  parenchyma  of  the  liver  than  was  consistent  with 
its  normal  state.  This  parenchyma  was  also  of  a pale  red  colour. 

In  the  cranium  and  chest  there  was  nothing  remarkable,  except  one  of  the 
lymphatic  glands,  which  was  changed  into  a bony  substance,  and  formed  a 
slight  tumour  before  the  arch  of  the  aorta. 

During  the  epidemic  cholera  in  Paris,  in  the  summer  of  1832,  we  saw  many 
cases  similar  to  the  preceding.  A great  many  persons,  after  having  had  dif- 
ferent degrees  of  cholera,  did  not  recover  perfectly  at  once  ; they  remained  for 
some  time  with  difficult  digestion,  more  or  less  acute  pain  in  the  epigastrium  ; 
they  also  had  nausea  and  vomiting.  In  several  these  symptoms  ceased  by 
little  and  little,  and  the  health  returned  ; but  in  others  the  stomach  became  more 
and  more  diseased ; the  vomiting  became  more  frequent ; a period  came  on 
when  all  liquids  were  rejected  by  vomiting ; very  often  there  were  frequent 
vomitings  of  greenish  bile  every  day  ; the  tongue  seldom  remained  in  its  natural 
state  ; being  at  first  white  and  moist,  it  afterwards  became  dry.  In  all  the  cases 
which  we  saw  there  was  continued  febrile  disturbance.  The  individuals  fell 


DISEASES  OF  TIIE  ABDOMEN. 


219 


rapidly  into  a state  of  marasmus,  and  they  died  at  an  interval  of  time  which  to 
us  seemed  to  vary  from  between  twenty-five  days  to  three  months.  In  those 
who  died  with  this  group  of  symptoms,  and  whose  bodies  were  examined  after 
death,  we  found  traces  of  inflammation  in  the  stomach.*  In  those  who  died  at 
a period  not  remote  from  the  commencement  of  the  disease,  we  found  the  gas- 
tric mucous  membrane  red  and  softened;  in  those  who  did  not  die  till  a later 
period,  this  membrane  sometimes  presented  the  same  aspect;  sometimes  it  pre- 
sented a brown  or  slate-coloured  tint,  and  its  tissue  was  thickened,  and,  as  it 
were,  indurated. 

In  such  cases  we  have  seen  the  most  active  antiphlogistic  treatment  com- 
pletely fail,  but  still  we  feel  convinced  that  it  was  the  treatment  on  which  most 
dependence  could  be  placed,  and  we  have  not  seen  the  other  treatment  em- 
ployed, either  by  ourselves  or  by  other  practitioners,  succeed  better. 

Case  5. — Symptoms  of  acute  gastritis — Death  on  the  nineteenth  day — Bright  redness  on  the 
inner  surface  of  the  stomach,  with  softening  of  all  the  substance  of  its  parietes. 

A young  man,  twenty-one  years  old,  in  the  habitual  enjoyment  of  good  health, 
entered  the  Charite  on  March  22d.  Ten  days  previously  he  had  lost  all  appe- 
tite. He  was  then  seized  with  an  acute  pain  in  the  epigastrium,  and  with  nausea 
and  vomiting.  When  he  was  placed  under  our  care  he  had  no  longer  any  vomit- 
ing, but  the  epigastrium  was  painful  on  pressure;  the  tongue,  covered  with  a 
thick  whitish  coat  at  its  centre,  was  of  a bright  red  colour  at  its  apex  and  edges. 
He  complained  of  a burning  thirst,  and  scarcely  ventured  to  satisfy  it,  because 
the  taking  of  drink  increased  the  epigastric  pains,  and  excited  nausea.  The 
pulse  was  very  frequent,  and  the  skin  hot.  He  was  bled  to  sixteen  ounces. 

He  was  then  in  the  eleventh  day  of  the  disease.  From  the  eleventh  to  the 
twelfth  day  there  was  incessant  vomiting.  On  the  tenth  day  the  features  of  the 
patient  were  as  much  altered  as  in  cases  of  the  most  acute  peritonitis ; he  was 
in  a state  of  indescribable  distress  ; his  voice  was  quite  gone,  as  in  cholera  ; the 
pulse  constantly  remained  very  frequent,  but  the  heat  of  skin  was  gone.  A 
large  blister  was  placed  on  the  epigastrium.  On  the  seventeenth  day  the  vomit- 
ing continued  ; it  was  not  large  in  quantity,  but  half  and  hour  did  not  pass  with- 
out the  patient  throwing  up  some  mouthfuls  of  greenish  bile.  On  the  eighteenth 
day  he  was  delirious.  On  the  nineteenth  countenance  hippocratic,  and  extreme 
exhaustion.  He  died  on  the  night  of  the  nineteenth. 

Post-mortem.  On  raising  the  stomach  for  the  purpose  of  examining  it,  we 
were  astonished  at  seeing  its  parietes  give  way  under  our  fingers  without  the 
slightest  force  being  used.  Over  all  the  left  portion  of  this  viscus,  its  tunics, 
from  the  peritoneal  to  the  mucous,  had  no  longer  any  consistence  : they  gave 
way  under  the  finger  like  a sort  of  pulp.  Wherever  this  softening  existed,  the 
parietes  of  the  stomach  were  of  a dark  red  colour,  and,  as  it  were,  ecchymosed. 
This  redness  was  very  considerable  on  the  inner  surface  of  the  organ.  Near 
the  pylorus  the  parietes  of  the  stomach  resumed  their  natural  consistence,  and 
in  this  part  the  mucous  membrane  had  a greyish  tint.  Nothing  remarkable 
in  any  other  part. 

This  case  differs  from  the  four  preceding  it  with  respect  to  the  nature  of  the 
alteration  of  which  the  stomach  was  the  seat.  The  inflammation  here  was  no 
longer  confined  to  the  mucous  membrane  ; it  extended  also  to  all  the  other 
tunics  ; and  the  result  was,  a softening  of  the  parietes  of  the  stomach,  resem- 
bling that  observed  by  M.  Cruveilhier  in  children,  and  described  by  him  under 
the  name  of  gelatiniform  softening  ; only,  here  the  softening  coincided  with  a 
very  intense  hyperaemia.  The  gastric  inflammation  was  announced  in  this  case 

* We  shall  presently  cite  cases  where,  with  symptoms  nearly  similar,  we  found  the  stomach 
exempt  from  all  appreciable  lesion  after  death. 


220 


ANDRAL’S  MEDICAL  CLINIC. 


during  life  by  very  well  marked  symptoms,  similar  to  those  pointed  out  in  the 
preceding  cases. 

We  met  a case  of  softening  of  the  stomach  entirely  similar  to  that  just  de- 
scribed, in  a young  child  to  which  sulphuret  of  potash  had  been  given  for  the 
cure  of  croup.  The  disease  yielded  ; but  the  child  did  not  ultimately  recover 
its  health.  He  died  in  a little  time,  after  having  presented  continual  vomiting 
as  a prevailing  symptom.  The  parietes  of  the  stomach,  through  their  entire 
extent,  presented  in  fact  nothing  but  a reddish  pulp,  which  crumbled  beneath 
the  finger. 

Case  6. — Constant  vomiting  for  forty  days — Ulceration  of  the  stomach. — Psoitis. 

A negress,  thirty  years  of  age,  was  in  the  habitual  enjoyment  of  good  health, 
when,  forty  days  before  entering  the  hospital  Pitie,  she  was  seized  with  pains  in 
the  epigastrium,  which  were  never  very  acute,  and  with  vomiting,  which  con- 
tinued up  to  the  time  of  her  admission.  Such  was  the  only  information  which 
we  could  obtain  regarding  the  previous  history  of  the  case. 

When  she  came  under  our  care' (March  10th,  1832)  she  had  reached  the  last 
stage  of  marasmus  and  debility ; she  had  fever  ; her  tongue  was  red  and  dry ; 
the  vomiting  had  lessened  ; she  would  take  nothing  but  a few  spoonsful  of  a solu- 
tion of  syrup  of  gum  in  water.  She  complained  of  no  pain  in  the  abdomen; 
she  continued  lying  on  her  back.  This  woman  remained  for  ten  days  in  the 
Pitie,  and  then  died,  having  pined  away  gradually.  Towards  the  termination 
of  life  she  ceased  to  vomit ; her  tongue  continued  red  and  dry  to  the  last,  and 
her  pulse  also  continued  frequent. 

Post-mortem.  The  internal  surface  of  the  stomach  was  white  through  its 
entire  extent,  and  the  mucous  membrane,  was  of  the  normal  consistence.  To 
the  right,  and  in  aline  with  the  cardiac  orifice,  at  the  distance  of  about  two 
inches  from  this  orifice  there  was  an  oblong  ulcer,  about  six  lines  in  length  and 
three  in  breadth  ; on  the  edges  of  this  ulcer  the  mucous  membrane  was  not  thick- 
ened, and  the  bottom  of  it  was  pale. 

The  remainder  of  the  intestine  was  pale  as  the  stomach.  To  the  extent  of  a 
foot  above  the  ileo-cascal  valve  there  were  observed  some  of  Peyer’s  patches,, 
recognisable  only  by  their  black  points.  They  formed  no  projection  above  the 
level  of  the  intestinal  surface.  The  colon  was  studded  with  a considerable  num- 
ber of  Brunner’s  follicles,  white  as  the  mucous  membrane  which  surrounded 
them.  The  liver  was  pale  and  soft ; the  spleen  was  small  and  soft.  One  of  the 
calices  of  the  left  kidney  was  filled  with  pus.  In  the  place  of  the  psoas  mus- 
cle of  the  leftside  there  existed,  an  immense  collection  of  pus,  in  which  the  bodies 
of  several  of  the  vertebrae,  divested  of  their  periosteum,  were  bathed. 

This  is  unquestionably  a very  remarkable  case  with  respect  both  to  the  symp- 
toms and  to  the  morbid  changes  which  occasioned  them.  An  ulcer  of  trifling  ex- 
tent, which  occupied  but  a few  lines  in  the  stomach,  and  no  other  alteration  of 
this  organ,  not  even  any  injected  vessel  through  its  entire  extent  ; no  change  in 
the  consistence  of  its  mucous  membrane  ; and  yet,  observe  how  severe  the 
symptoms  were  with  respect  to  the  stomach;  is  there  notreason  to  be  astonished 
at  the  long-continued  and  obstinate  vomiting,  when  we  consider  that  ulcerations 
of  the  stomach,  though  of  vast  extent,  and  accompanied  with  many  other  orga- 
nic lesions,  oftentimes  do  not  give  rise  to  any  vomiting?  Nor  can  we  avoid 
remarking  the  coincidence  between  the  redness  and  dryness  of  the  tongue  with 
such  a state  of  the  stomach. 

No  doubt  the  profuse  suppuration  of  the  psoas  muscle  had  a great  share  in 
the  production  of  some  of  the  symptoms  ; but  though  we  may  refer  the  fever 
and  emaciation  partly  to  this  cause,  we  can  scarcely  allow  that  this  suppuration 
was  the  cause  of  the  vomiting. 

What  was  the  origin  of  the  purulent  matter  found  in  one  of  the  calices  ? Had 


DISEASES  OF  THE  ABDOMEN. 


221 


it  been  secreted  there  ? But  no  trace  of  inflammation  was  found  around  it. 
Was  it  conveyed  there  by  absorption  ? This  would  not  be  the  first  time  we 
found  pus  in  the  urine  without  any  vestige  of  inflammation  in  the  kidneys, 
ureters,  or  bladder,  at  the  same  time  that  there  was  a purulent  collection  in 
other  points  of  the  body. 

Case  7. — Numerous  ulcerations  on  the  inner  surface  of  the  stomach — Diphtheritic  eruption 
over  the  entire  buccal  mucous  membrane — Pulmonary  tubercles. 

A woman,  twenty-six  years  of  age,  entered  the  Pitie,  during  the  summer  of 
1832,  with  all  the  signs  of  pulmonary  phthisis  in  a far  advanced  stage.  During 
the  last  twenty  days  of  its  existence*  the  tongue,,  gums,  lips,  and  cheeks,  were 
covered  with  a whitish  layer,,  resembling  the  eruption  of  aphthae  ( muguet ). 
The  entire  mouth  was  at  the  same  time  the  seat  of  acute  pain  ; there  was  a 
complete  loss  of  appetite,  burning  thirst ; the  epigastrium  was  habitually  painful. 
From  time  to  time  the  patient  had  some  nausea,  but  never  any  vomiting.  She 
died  on  the  29th  of  June. 

Post-mortem.  — The  internal  surface  of  the  stomach  was  lined  with  a thick 
layer  of  brownish  mucus,  which  closely  adhered  to  the  mucous  membrane  ; the 
latter,  through  its  entire  extent,  actually  presented. the  appearance  of  a sieve*  in 
consequence  of  a multitude  of  small  ulcerations,  all  of  the  same  form  and  the 
same  size ; they  were  exactly  rounded,  each  being  scarcely  the  size  of  a 
centime.  The  bottom  of  these  was  formed  by  the  submucous  cellular  tissue* 
which  still  retained  its  natural  whiteness  and  thickness.  Beside  these  ulcera- 
tions there  were  observed  some  depressions,  at  the  bottom  of  which  the  mucous 
membrane  was  still  found  reduced  to  a very  fine  web,  and  covered  by  a blackish 
matter,  which  seemed  to  be  the  detritus  of  the  most  superficial  plane  of  the 
mucous  membrane.  Between  these  ulcerations  and  these  vacuities,  the  mucous 
membrane  retained  its  natural  thickness  and  consistence ; it  was  every  where 
white,. except  towards  the  small  curvature,  to  the  extent  of  a five-franc  piece, 
where  some  bright  red  points  were  observed. 

The  duodenum  presented,  on  its  inner  surface,  three  black  spots,  which  were 
formed  of  mucous  membrane  thickened,  and  as  it  were  infiltrated,  with  a black 
substance,  which  towards  the  edges  of  each  spot  assumed  a red  tint.  A little 
below  these  three  spots,  towards  the  union  of  the  second  and  third  curve  of  the 
duodenum,  an  ulcer  was  observed,  which  was  still  covered  by  some  debris  of  the 
black  substance  just  mentioned.  Numerous  ulcerations,  through  which  tubercles 
were  observed,  were  remarked  on  the  lower  third  of  the  small  intestine,  in  the 
caecum,  and  at  the  commencement  of  the  colon. 

A brownish  substance  lined  the  oesophagus.  The  internal  surface  of  this  tube 
presented  some  longitudinal  bands,  where  the  epithelium  was  wanting;  it  was 
here  principally,  that  the  black  matter  was  accumulated.  Tubercles  and  cavities  in 
the  lungs.  Traces  of  peritonitis,  with  numerous  tubercles  amidst  false  membranes. 
Liver  pale,  friable,  and  greasing  the  scalpel. 

We  have  cited  this  ease  for  the  express  purpose  of  pointing  out  the  remark- 
able alteration  which  was  found  in  the  stomach.  The  numerous  ulcerations 
observed  on  its  internal  surface,  had  probably  been  formed  in  each  of  the  points 
where  they  existed  by  these  black  spots,  some  of  which  were  still  entire  in  the 
duodenum.  What  was  their  nature  ? Were  they  so  many  small  eschars  which 
had  succeeded  a multitude  of  small  circumscribed  inflammations  of  the  mucous 
membrane,  similar  to  those  of  which  we  had  an  instance  in  the  fourth  case  ? 
Observe  also,  that  in  several  points  the  mucous  membrane  was  destroyed  only 
in  its  more  superficial  plane,  in  that  which  is  principally  formed  of  villi ; these 
were  replaced  by  the  black  substance  already  mentioned. 

With  respect  to  the  symptoms,  there  were  none  connected  with  the  sto- 
mach, except  an  habitual  pain  in  the  epigastrium.  It  is  not  certain  that  the 
19* 


222 


ANDRAL’S  MEDICAL  CLINIC. 


affection  of  the  month  depended  on  the  state  of  the  stomach  ; and  if  it  be  true 
that  we  have  more  than  once  seen  this  affection  develope  itself  in  the  last  stage 
of  acute  or  chronic  gastritis,  it  is,  on  the  other  hand,  equally  true  that  we  have 
found  the  stomach  perfectly  healthy  in  cases  where  the  entire  buccal  mucous 
membrane  had  remained  for  a long  time  covered  with  patches  of  diphtherite. 

Case  8. — Acute  pain  in  the  epigastrium  ; super-acute  peritonitis — Perforation  of  the  stomach. 

A woman,  thirty  years  of  age,  labouring  under  pulmonary  phthisis,  continued 
to  eat,  and  to  digest  tolerably  well,  though  she  for  a long  time  had  been  trou- 
bled with  diarrhoea.  One  day  she  complained  of  an  acute  pain  in  the  epigas- 
trium, and  she  had  several  attacks  of  vomiting;  at  first,  she  threw  up  her  food, 
and  then  a considerable  quantity  of  thready  mucus  and  bile.  Thirty  hours 
passed  on  in  this  way  ; after  which  the  entire  abdomen  became  tense,  and  very 
painful  to  the  touch,  all  the  signs  of  acute  peritonitis  appeared,  and  the  patient  died 
rapidly. 

Post-mortem.  A purulent  liquid  filled  the  cavity  of  the  peritoneum,  and 
membranous  concretions  covered  the  stomach  and  intestines.  On  raising  the 
stomach  we  discovered  on  the  posterior  part  of  the  great  cul-de-sac,  not  far  from 
the  cardia,  a perforation  through  which  the  index  finger  might  be  easily  admit- 
ted. Around  this  perforation,  the  coats  of  the  stomach  were  irregularly  torn, 
softened,  and  as  it  were  ecchymosed.  All  the  inner  surface  of  the  great  cul-de- 
sac  was  of  a livid  red  colour,  and  its  parietes  were  very  friable.  The  mucous 
membrane  of  the  stomach  through  the  rest  of  its  extent  was  very  much  in- 
jected. 

Ulcerations  at  the  end  of  the  small  intestines.  Cavities  in  the  lungs. 

This  is  an  instance  of  these  solutions  of  continuity  of  the  stomach,  which 
several  authors  have  described  under  the  name  of  spontaneous  perforations,  and 
which  seem  to  us  to  be  nothing  else  than  the  result  of  a very  acute  inflamma- 
tion of  the  stomach  ; all  the  coats  are  then  found  to  be  simultaneously  affected, 
all  are  softened,  and  ulcerated  at  the  same  time,  and  after  the  lapse  of  a very 
short  time  the  perforation  may  thus  be  completed.  We  have  seen  persons  die 
in  this  way  in  a few  hours,  just  as  if  a violent  corrosive  poison  had  been  intro- 
duced into  their  stomach.  It  is  remarkable  enough  that,  in  most  of  the  cases 
of  this  kind  which  have  been  described,  as  also  in  those  seen  by  ourselves,  the 
perforation  took  place  towards  the  great  cul-de-sac. 


CHAPTER  II. 

OBSERVATIONS  ON  CHRONIC  GASTRITIS. 

Under  the  generic  term  chronic  gastritis  we  comprise  several  alterations 
which  are  usually  described  as  diseases  entirely  of  a distinct  nature  — such,  for 
example,  as  cancer  of  the  stomach.  If,  accordingly,  these  alterations  appear  to 
be  very  different  from  each  other,  with  respect  to  their  anatomical  characters, 
they  resemble  each  other,  and  become  really  confounded,  both  in  regard  to  the 
symptoms  which  indicate  their  existence,  and  which  no  more  appertain  exclu- 
sively to  the  one  than  to  the  other;  and  also  with  respect  to  the  nature  of  the 
occasional  causes  which  give  rise  to  them,  and  which  are  identical  for  all ; and 
lastly,  in  reference  to  the  treatment,  which,  likewise,  should  be  the  same  for  all- 
If  then  these  different  alterations  should  be  distinguished  from  one  another,  in 
consideration  not  only  of  the  varieties  of  their  form  and  texture,  but  chiefly  in 
consequence  of  their  different  degrees  of  curability,  it  is  no  less  true,  that,  taken 
at  their  original  seat,  they  all  present  one  very  important  common  element, 


DISEASES  OF  THE  ABDOMEN. 


223 


namely,  the  irritation  which  precedes  them  in  their  development.  The  generic 
term  gastritis,  under  which  we  comprehend  such  variable  alterations  of  texture, 
appears  to  us  useful  only  in  so  far  as  it  expresses  the  general  cause,  and  the  com- 
mon connexion  of  these  alterations.  But  the  question  is  not  confined  to  this ; after 
having  seized  the  point  in  which  these  alterations  approximate  to  each  other  — 
an  important  point,  since  with  it  is  connected  the  treatment  — it  is  necessary 
to  discover  the  cause  of  their  differences-.  These  cannot  be  explained  either  by 
the  intensity  or  duration  of  the  irritation.  It  is  even  a remarkable  circumstance, 
that  the  most  serious  alterations  of  texture  are  often  those  which  are  preceded 
or  accompanied  by  the  signs  of  the  slightest  irritation.  What  shall  we  conclude 
from  this  circumstance  ? This,  thatin  order  to  account  for  effects  so  dissimilar, 
we  shall  be  forced  to  admit  certain  predisposing  causes  peculiar  to  each  of  them, 
and  to  acknowledge,  that  irritation  no  longer  acts,  except  as  a simple  occasional 
cause,  which  of  itself  would  be  unable  to  produce  any  of  the  alterations.  If  this 
be  so,  what  can  be  the  effect  of  the  antiphlogistic  treatment  ? It  combats  only  this 
occasional  cause;  but  it  does  not  at  all  destroy  the  predisposing  cause,  which, 
once  the  irritation  is  produced,  gives  rise,  according  to  its  nature,  to  the  most 
varied  lesions.  Thence  the  frequent  inefficacy  of  this  treatment,  which  attacks 
only  one  of  the  elements  of  the  disease,  and  which  does  not  at  all  destroy  the 
unknown  cause,  under  the  influence  of  which  the  irritation  itself  comes  on.  We 
would  not  consider  it  unreasonable  to  maintain  that  in  certain  cases  the  unusual 
afflux  of  blood  by  which  the  irritation  is  made  manifest  takes  place  in  an  organ 
only  because  there  already  exists  in  this  organ  a morbid  predisposition,  which 
draws  more  blood  to  it  than  in  the  natural  state,  so  that  a secretion,  or  a morbid 
nutrition,  comes  to  be  established  in  its  tissue.  We  see,  then,  how  secondary 
a part  sanguineous  congestion  performs  in  such  cases,  and  how,  by  admitting 
it,  we  are  still  far  from  having  penetrated  the  essence  of  the  phenomena.  It 
would  be  a strange  mistake  to  suppose,  that,  by  it,  we  could  account  for  the 
formation  of  different  organic  alterations,  and  explain  their  numberless  varieties. 
Thus,  when  the  embryo  is  developed,  the  afflux  of  blood  into  the  tissue  of  the 
different  organs  is  a condition  of  the  formation  of  the  latter,  it  is  the  common  ele- 
ment which  we  shall  find  for  all  organic  formation  ; but  it  is  not  this  afflux  of 
blood  which  determines  the  special  nature  of  each  organ,  its  chemical  composi- 
tion, its  anatomical  arrangement,  and  its  vital  properties.  Thus,  every  secre- 
tion recognises  this  same  afflux  as  a condition  of  its  existence  ; but  it  is  not  by 
the  mere  increased  quantity  of  the  blood,  and  by  the  mere  excitement  occasioned 
by  it  in  the  organ  which  receives  it,  that  we  can  explain  why  each  gland  secretes 
a peculiar  liquid. 

We  entreat  the  reader  not  to  lose  sight  of  these  considerations  ; if  he  reflect 
attentively  on  them,  we  trust  . he  will  not  reproach  us  with  having  combined 
alterations  which  seem  so  different  from  each  other*  under  the  common  term  of 
chronic  gastritis  ; this  term  we  use  merely  as  a sort  of  general  expression, 
under  which  is  ranged  every  organic  affection  of  the  stomach,  against  which 
the  antiphlogistic  treatment  seems  to  succeed  better  than  any  other. 

Let  us  endeavour  then  to  show,  either  by  anatomy,  or  by  the  study  of  the 
symptoms,  how  certain  organic  or  functional  lesions  succeed  each  other,  and 
are  linked  together  in  the  stomach,  the  nature  of  which  was  for  so  long  a time 
mistaken  because  their  description  was  given  separate,  medical  men  being  per- 
suaded that  each  of  these  lesions  constitute  a disease  in  itself. 


ARTICLE  I. 

ALTERATIONS  PRODUCED  IN  THE  STOMACH  BY  CHRONIC  GASTRITIS. 

These  alterations  are  as  numerous  as  they  are  varied  ; they  are  so  much  the 
more  important  to  be  known,  inasmuch  as,  though  it  often  happens  that  differ- 


224 


ANDRAL’S  MEDICAL  CLINIC. 


ent  as  they  are,  they  give  rise  to  the  same  functional  disturbances,  they  at  other 
times  produce  symptoms  which  vary  with  them.  In  more  than  one  case  may 
we  explain  the  equally  certain  success  of  opposite  modes  of  treatment  by  the 
difference  of  the  lesions,  of  which  the  stomach,  when  in  a state  of  chronic  in- 
flammation, has  become  the  seat. 


SECTION  I. 

ALTERATIONS  OF  THE  MUCOUS  MEMBRANE. 

In  the  great  majority  of  cases  of  chronic  gastritis,  anatomy  proves  the  exist- 
ence of  varied  and  more  or  less  considerable  alterations  in  the  mucous  mem- 
brane of  the  stomach.  Sometimes,  however,  this  membrane  appears  to  have 
retained  its  healthy  state,  or  at  least  it  is  certain,  that  if  it  underwent  any  altera- 
tion, this  alteration  entirely  escapes  anatomical  inspection.  Thus,  through  its 
entire  extent  it  presents  the  white  colour  which  constitutes  its  normal  state  ; in 
every  part,  also,  it  presents  its  ordinary  consistence  ; it  is  neither  softened 
nor  indurated  ; in  no  part  of  it,  in  a word,  does  its  substance  appear  to  be  either 
increased,  or  diminished.  But  then  we  observe  beneath  the  healthy  mucous 
membrane,  different  and  very  striking  affections  of  subjacent  tissues,  and  par- 
ticularly of  the  cellular  tissue  extended  in  the  form  of  a dense  and  whitish  mem- 
brane between  the  villous  coat  of  the  stomach  and  its  muscular  coat.  Here, 
however,  a question  presents  itself : though  the  mucous  membrane  may  ap- 
pear perfectly  healthy  at  the  time,  has  it  always  been  so  ? was  there  not  a 
stage  of  the  disease  at  which  it  was  affected,  and  should  we  not  even  suppose, 
that,  in  most  instances,  it  is  in  the  mucous  membrane  that  the  chronic  affection 
has  commenced,  of  which  we  no  longer  find  any  traces,  except  in  the  tissues 
placed  beneath  it?  In  order  to  solve  this  question,  which  is  important,  with 
respect  to  the  etiology  of  the  diseasej  and  to  its  treatment,  let  us  first  interrogate 
analogy. 

When  a membranous  or  parenchymatous  tissue  is  attacked  with  inflamma- 
tion, sometimes  the  parts  in  contact  with  this  tissue  remain  unaffected  by  the 
morbid  process,  sometimes  they  participate  in  it.  If  the  latter  be  the  case,  it 
often  happens  that,  in  the  tissue  primarily  affected,  particularly  if  it  possess  a 
considerable  share  of  vitality,  the  inflammation  becomes  resolved,  whilst  it  con- 
tinues and  passes  into  the  chronic  state  in  the  tissues,  which  were  but  second- 
arily affected  ; this  happens  particularly  when,  in  the  latter  tissues,  the  vital 
properties  are  less  active  and  less  energetic  than  in  the  tissue  which  was  first 
attacked  by  inflammation.  In  support  of  these  assertions  very  many  instances 
present  themselves.  I shall  cite  some.  A person  becomes  attacked  with  en- 
teritis or  colitis ; if  he  dies  in  the  acute  stage,  we  find  only  the  mucous  mem- 
brane affected,  either  merely  red,  or  softened,  or  ulcerated,  etc.  ; if  the  patient 
does  not  die  till  after  a longer  time,  after  the  inflammation  has  taken  on  a 
chronic  form,  the  intestine  may  present  three  different  states  : — first,  the  inflam- 
mation may  be  limited  solely  to  the  mucous  membrane  ; secondly,  simultane- 
ously with  this  membrane,  the  tissues  subjacent  to  it  may  have  undergone  dif- 
ferent alterations,  the  result  no  doubt  of  the  inflammation  which  has  attacked 
them  ; but  sometimes  the  mucous  membrane  and  the  subjacent  tissues  seem 
to  be  almost  equally  diseased,  sometimes  the  latter  seem  to  be  much  more  so; 
and  cases  may  even  present  themselves  in  which  the  alteration  of  the  mucous 
membrane,  escaping  observation  at  first,  can  be  discovered  only  by  attentive  ex- 
amination. Thus,  this  membrane,  though  white,  is  softened,  and  is,  as  it  were, 
pulpy  in  several  points  ; at  other  times  it  presents  a grey,  brown,  or  black 
colour,  arranged  in  simple  points,  isolated  or  aggregated,  in  round  patches, 
sinuous  lines,  longhands,  etc.  ; at  other  times  it  presents  superficial  ulcerations, 


DISEASES  OE  THE  ABDOMEN. 


225 


white  as  the  rest  of  the  membrane,  the  bottom  of  which  is  on  a level  with  the 
edges,  and  which  are  evidently  progressing  towards  complete  cicatrization.  We 
now  observe  here  only  the  remains  or  vestiges  of  the  inflammation  of  the  mu- 
cous membrane;  but  this  white  softening,  this  form  of  ulceration,  proves  that 
more  intense  inflammation  has  existed  in  this  membrane  ; in  fact,  it  is  these 
same  lesions  which  are  found  in  persons  who  have  died  accidentally  during  con- 
valescence from  acute  gastro-enterilis  ; that  is,  at  a period  when  one  should  no 
longer  find  in  the  intestinal  canal  any  thing  but  the  remains  of  an  inflammation 
which  had  been  much  more  severe  there  : it  is  again  these  same  forms  of  lesion 
which  are  found  in  the  buccal  or  pharyngeal  mucous  membrane,  when  the  in- 
flammation, of  which  it  had  been  the  seat,  is-  tending  to  resolution,  when  the 
ulcerations,  with  which  it  had  been  covered,  are  beginning  to  cicatrise.  Thus 
then  it  seems  very  probable,  that  in  the  case  now  in  question,  the  mucous  mem- 
brane was  much  more  seriously  affected  than  it  is  now  found,  and  that  the  in- 
flammation, of  which  it  was  the  seat,  still  continuing  in  the  subjacent  tissues,  is 
progressing  towards  complete  resolution  ; thirdly,  from  what  has  been  just  said, 
it  is  easy  to  conceive  that  cases  may  present  themselves,  in  which  these  last 
traces  of  inflammation  of  the  mucous  membrane  shall  have  completely  disap- 
peared, and  where  it  will  seem  to  be  perfectly  healthy  at  the  same  time  that  the 
tissue  subjacent  to  it  are  more  or  less  severely  disorganized.  Nor  is  this  third 
case  very  uncommon. 

In  the  pulmonary  mucous  membrane  we  may  observe  the  same  succession  of 
phenomena.  Thus  in  acute  bronchitis  the  mucous  membrane  alone  seems  to 
be  affected ; in  chronic  bronchitis  there  is  a degree  of  it  in  which  we  observe, 
at  one  and  the  same  time,  alterations,  more  or  less  varied,  of  the  mucous  mem- 
brane, and  very  remarkable  lesions  of  the  subjacent  tissues,  particularly  thicken- 
ing of  the  mucous  membrane,  and  hypertrophy  of  the  cartilaginous  rings. 
Again,  there  is  another  degree  of  it  in  which  the  mucous  membrane  has  re- 
covered its  healthy  state,  at  least  apparently  so,  and  where  we  only  perceive 
an  alteration  of  the  other  tunics  of  the  air  tubes.  Cases  of  this  kind  have  been 
already  cited. * 

If  these  examples  were  not  sufficient  to  prove  that,  in  a great  number  of  cases 
at  least,  the  alteration  of  the  tissues  subjacent  to  the  mucous  membrane  has  its 
origin  in  an  inflammation  of  these  membranes,  which  may  still  continue,  and 
which  has  completely  disappeared,  I might  still  cite  other  cases  in  which  this 
succession  of  phenomena  may  be,  in  some  measure,  appreciated  by  the  finger 
and  the  eye.  Thus,  after  more  or  less  intense  inflammation  of  the  conjunctiva, 
and  when  this  membrane  has  recovered  its  natural  whiteness  and  transparence, 
the  cellular  tissue  which  connects  it  to  the  sclerotic,  may  continue  inflamed,  in- 
filtrated with  pus,  be  thickened,  and  become  the  seat  of  various  morbid  changes. 
Thus,  in  persons  who  formerly  had  gonorrhoea,  and  in  whom  the  urethra  has 
become  contracted  in  various  parts,  the  mucous  membrane  has  been  found  per- 
fectly healthy,  but  the  cellular  tissue  beneath  it  is  thickened  and  indurated.  It 
is  in  this  way,  also,  that  in  certain  individuals,  who  have  for  a long  time  had  a 
chronic  inflammation  of  part  of  the  skin  — who,  for  instance,  have  had  sores 
on  the  legs  — the  cellular  tissue  subjacent  to  the  diseased  portions  of  the  skin 
is  also  inflamed,  and  retains  a scirrhous  hardness  as  it  were,  long  after  all  traces 
of  inflammation  have  disappeared  from  the  skin.  I might  again  cite  cases  of 
acute  or  chronic  inflammation  of  the  serous  or  synovial  membranes,  in  which 
these  membranes  having  returned  to  a perfectly  healthy  state,  there  have  been 
found  in  the  subjacent  cellular  tissue  traces  of  chronic  inflammation,  such  as 
induration,  scirrhous  thickening,  fibrous  or  cartilaginous  transformation,  etc. 

Reasoning  then  from  analogy,  we  might  be  inclined  to  admit,  that  the  kind 

* See  the  parts  of  this  work  which  treat  of  diseases  of  the  chest. 


226 


ANDllAL’S  MEDICAL  CLINIC. 


of  law  which  we  have  proved  to  exist  with  respect  to  the  intestinal  canal,  the 
air  passages  in  the  mucous  membrane  of  the  eye,  in  that  of  the  urethra,  in  the 
skin,  in  the  serous  and  synovial  tissues,  exists  also  with  respect  to  the  stomach  : 
that  is,  the  inflammation  of  which  we  no  longer  find  any  traces  except  in  the 
tissues  subjacent  to  the  mucous  membrane  of  this  organ,  primarily  existed  in 
this  mucous  membrane.  But  further,  for  the  stomach,  as  for  the  other  organs 
in  question,  this  proposition  may  be  demonstrated  by  direct  proofs.  Thus,  in 
the  mucous  membrane  of  the  stomach,  as  in  that  of  the  intestine,  I have  been 
able  more  than  once  to  trace  the  gradation  of  the  inflammation,  and  to  ascertain, 
with  more  or  less  exactness,  the  different  stages  through  which  the  mucous 
membrane  passed,  if  I may  so  say,  in  order  to  return  from  the  morbid  to  the 
healthy  state.  Thus,  at  the  same  time  that  different  alterations  of  the  subjacent 
tunics  existed,  I sometimes  found  the  mucous  membrane  red,  thickened,  softened, 
occasionally  ulcerated ; sometimes  these  traces  of  inflammation  of  the  mucous 
membrane  were  much  less  evident : it  was,  for  instance,  soft,  but  white  ; some- 
time it  was  very  evident,  from  the  nature  of  the  changes,  that  the  mucous  mem- 
brane had  been  much  more  diseased  than  it  appeared  to  be  at  the  time  the 
examination  was  made.  In  one  case,  for  instance,  which  I saw  at  the  Charite, 
with  my  friend  and  colleague,  M.  Reynaud,  we  found  the  internal  surface  of 
the  stomach  white  through  its  entire  extent ; towards  the  pylorus  there  was 
evident  induration  of  the  sub -mucous  cellular  tissue,  with  hypertrophy  of  the 
muscular  membrane.  These  tissues,  as  they  proceeded  from  the  pylorus, 
resumed  their  healthy  appearance  ; then,  towards  the  middle  of  the  stomach, 
the  parietes  of  this  organ  presented  a new  thickening,  a cartilaginous  sort  of 
hardness  ; this  induration  resided  solely  in  the  different  tissues  subjacent  to  the 
mucous  membrane  ? over  the  entire  extent  of  this  thickening,  which  was  about 
equal  to  a five-franc  piece,  the  mucous  membrane  itself  no  longer  existed.  The 
result  of  this  was  an  ulceration  so  superficial,  with  white  edges,  and  the  bottom 
equally  white,  and  on  a level  with  the  edges,  that  it  was  not  perceptible  at  the 
first  glance.  The  bottom  was  formed  of  cellular  tissue  considerably  thickened. 
The  individual  in  whom  this  morbid  change  was  found,  had  experienced,  three 
years  before,  all  the  sy  mptoms  of  acute  gastritis,  such  as  pain  in  the  epigastrium, 
with  fever,  vomiting,  ardent  thirst,  etc.  These  symptoms  gradually  improved  ; 
but  from  this  period  the  patient  continued  to  labour  under  painful  digestion,  and 
from  time  to  time  his  food  was  thrown  up.  Chronic  peritonitis  contributed  to 
accelerate  his  death. 

Very  probably  there  was  a period  when  the  solution  of  continuity  of  the 
mucous  membrane  in  this  individual  had  presented  characters  in  some  measure 
more  inflammatory  than  those  discovered  when  the  body  was  opened; 
very  probably,  around  this  solution  of  continuity,  the  mucous  membrane 
had  been  more  or  less  inflamed.  The  ulceration  appeared  to  progress  to- 
wards cicatrization ; after  some  time  still  the  mucous  membrane  would  pro- 
bably have  been  found  white  and  healthy  above  the  thickening  of  the  middle 
part  of  the  stomach,  as  it  was  found  white  and  healthy  above  the  thickening 
near  the  pylorus.  If,  however,  from  the  mere  examination  after  death, 
there  could  still  be  a doubt  that  the  inflammation  of  the  mucous  membrane 
had  been  in  this  case  the  original  affection,  and  that  it  had  existed  previously 
to  the  alterations  of  the  other  tunics,  and  that  the  lesions  which  it  presented 
were,  in  some  measure,  but  the  vestiges  of  more  serious  lesions,  we  would 
appeal  to  any  other  source  of  information,  we  would  interrogate  the  symp- 
toms; and  from  their  order  of  succession  we  would  draw  the  inevitable 
conclusion,  that  the  tissue  primarily  inflamed  was  the  mucous  membrane  (first 
stage  of  the  disease  ; gastritis  in  the  acute  form)  ; that,  subsequently,  the  in- 
flammation of  this  membrane  became  less  intense  (cessation  of  the  fever  and 
of  the  epigastric  pain) ;.  that  it  continued,  however,  at  the  same  time  that  tho 


DISEASES  OF  THE  ABDOMEN. 


227 


subjacent  tissues  became  consecutively  diseased  (difficulty  of  digestion  ; habitual 
anorexia  ; vomiting  becoming  more  and  more  infrequent). 

Lastly,  when  the  mucous  membrane  of  the  stomach  has  recovered  its  white- 
ness and  natural  consistence,  and  when  there  is  at  the  same  time  induration  of 
the  subjacent  tissues,  should  we,  in  all  cases,  consider  this  membrane  as  returned 
to  its  perfectly  normal  state  ? Observe,  that  in  several  of  these  cases  where 
the  mucous  membrane  appears  perfectly  healthy  to  the  eye  of  the  anatomist, 
digestion  continues  painful  and  laborious,  such  as  it  exists  in  persons  whose 
mucous  membrane  presents,  after  death,  more  or  less  marked  traces  of  chronic 
inflammation.  It  seems,  then,  that  in  cases  of  this  kind  the  mucous  membrane 
recovers  the  appearance  which,  at  least  as  far  as  our  feeble  means  of  investiga- 
tion go,  constitutes  its  normal  state,  before  it  recovers  the  integrity  of  its  func- 
tions ; it  seems  there  is  a period  when  this  membrane  is  no  longer  inflamed, 
but  when  it  has  not  yet  the  power  of  producing  on  the  food  that  modification 
which  should  convert  it  into  chyme,  whatever  be  the  physical,  chemical,  or 
vital  process  by  which  this  change  is  effected.  It  is,  moreover,  not  in  the  mu- 
cous membrane  of  the  stomach  only  that  we  shall  find  instances  of  tissues, 
which,  after  having  been  the  seat  of  inflammation  more  or  less  evident,  have 
recovered  a healthy  appearance,  whose  functions  are  still,  however,  consider- 
ably  altered.  Thus,  in  some  persons  who  presented  during  life  all  the  symp- 
toms of  chronic  bronchitis,  with  copious  purulent  expectoration,  I found  the 
mucous  membrane  of  the  larynx,  trachea,  and  bronchi,  white,  and  to  all  appear- 
ance healthy.  From  mere  anatomical  inspection  one  would  not  have  hesitated 
to  admit  that  this  membrane  was  perfectly  healthy  ; and  yet  the  copious  puri- 
form  secretion,  of  which  it  was  the  seat,  proved  its  pathological  condition. 

The  healthy  appearance,  at  least  apparently  so,  of  the  mucous  membrane  of 
the  stomach  in  cases  of  chronic  gastritis,  is,  however,  rather  a rare  circumstance, 
and  most  frequently  it  presents  different  changes  with  respect  to  its  colour, 
consistence,  thickness,  and  form.  These  varied  alterations  may  exist  separate, 
or  combined.  Thus,  at  the  same  time  that  the  mucous  membrane  is  red  and 
brown,  it  may  be  indurated  or  softened,  hypertrophied  or  attenuated,  etc.  At 
other  times,  some  one  or  other  of  these  alterations  may  present  itself  alone  ; 
there  may  be,  for  instance,  mere  change  of  colour  ; at  other  times,  a thing  more 
remarkable,  the  consistence  of  the  mucous  membrane  is  found  to  be  considerably 
diminished,  without  its  colour  having  undergone  any  change. 

Are  the  changes  which  the  inflamed  mucous  membrane  undergoes  in  its 
colour  different  in  acute  and  in  chronic  inflammation  of  the  stomach  ? There 
are  some  shades  of  colour  which  belong  equally  to  these  two  states  ; there  are 
others  which  denote  more  particularly  the  existence  of  a chronic  inflammation. 

The  shades  of  colour  which  principally  belong  to  chronic  gastritis  are  the 
grey  slate-colour,  the  brown  colour,  and,  lastly,  the  more  or  less  deep  black 
colour.  I do  not  mean  to  say  that  these  different  tints  may  not  also  be  found 
in  some  cases  of  very  acute  inflammation  ; they  have  been  sometimes  produced 
by  Professor  Orfila  in  animals,  into  whose  stomach  this  learned  and  skilful  ex- 
perimentalist had  introduced  irritating  substances.  In  the  human  subject  there 
are,  I think,  very  few  instances  of  the  grey  slate-colour,  or  of  the  brown  or 
black  colour,  being  found  in  stomachs  affected  with  acute  inflammation;  nothing, 
on  the  contrary,  is  more  common  in  chronic  gastritis.  It  is  probable,  that  in 
the  human  subject,  as  well  as  in  those  animals  experimented  on  by  M.  Orfila, 
the  acute  inflammation  was  chiefly  observed  with  these  shades  of  colour  only 
in  cases  of  poisoning  by  acrid  or  corrosive  substances  ; that  is  to  say,  in  cases 
where  the  inflammation  of  the  stomach  having  in  some  measure  attained  its 
most  acute  form,  tends  to  produce  rapid  disorganization  of  the  mucous  mem- 
brane. 

It  seems  to  me  remarkable  enough  that  the  same  colouring  is  observed  in  the 


228 


ANDRAL’S  MEDICAL  CLINIC. 


two  extremes,  if  I may  say,  of  gastritis  ; namely,  in  super-acute  inflammation, 
which  proves  fatal  very  rapidly,  and  in  chronic  inflammation,  which  oftentimes 
indicates  its  existence  by  very  slight  symptoms.  This  is  the  fact,  such  as  ex- 
perience presents  it  to  us.  In  order  to  explain  it,  it  would  be  necessary  ac- 
curately to  know  what  is  the  cause  of  the  brown,  grey  slate-colour,  etc.,  which 
the  mucous  membrane  of  the  stomach  presents,  both  in  the  case  of  super-acute 
gastritis,  and  more  frequently  still  in  the  case  of  chronic  gastritis.  Now,  on 
this  point  we  can  only  form  mere  conjecture,  which  rests  on  such  facts  as 
these  : Hunter,  long  ago,  proved  that  every  time  arterial  blood  is  arrested,  or 
even  merely  retarded  in  its  course,  it  takes  on  the  colour  of  venous  blood. 
Thus,  for  instance,  if  we  open  an  artery  in  an  animal,  in  a portion  of  the  vessel 
previously  intercepted  between  two  ligatures,  black  blood  issues  from  it,  re- 
sembling venous  blood.  Hunter  has  also  remarked,  that  the  blood  which  comes 
from  a divided  artery,  and  which  is  effused  into  the  surrounding  cellular  iissue, 
also  becomes  black  on  coagulating  there.  This  same  black  colouring  is  also 
found  in  the  blood  of  the  majority  of  the  cases  of  cerebral  apoplexy,  and  in  that 
of  pulmonary  apoplexy.  Unless  it  be  supposed,  a thing  not  at  all  probable, 
that  in  these  hemorrhages  veins  only  supply  the  blood,  it  must  be  admitted,  that 
in  the  brain  and  lung,  the  blood,  red  at  the  time  when  the  effusions  take  place, 
subsequently  acquired  the  black  colour  which  it  presents.  Can  we  in  a similar 
manner  explain  the  brown  or  black  colouring  of  the  mucous  membrane  of  the 
stomach  in  a certain  number  of  cases  of  gastritis  ? For  this  purpose  it  is  neces- 
sary that  experience  should  have  ascertained,  that  there  are  cases  wherein  the 
blood  in  an  inflamed  part  circulates  more  slowly  than  in  the  same  part  when 
healthy,  and  wherein  it  even  has  a tendency  actually  to  stagnate  in  this  in- 
flamed part.  Now,  this  retardation  of  the  circulation  of  the  blood  in  an  inflamed 
tissue  has  been  proved  by  the  experiments  of  Dr.  Wilson  Philip.  An  inflam- 
mation being  produced  in  the  cellular  tissue  of  a frog’s  thigh,  in  the  fin  of  a fish, 
or  in  the  mesentery  of  a rabbit,  the  microscope,  says  Dr.  W.  Philip,  soon  shows 
that  the  motion  of  the  globules  of  the  blood,  which  is  ordinarily  so  rapid,  is  per- 
ceptibly retarded,  it  seems  to  be  even  altogether  suspended  in  the  part  where 
the  inflammation  appears  most  intense.  If  then  it  is  proved,  on  the  one  hand, 
that  under  certain  circumstances  the  blood  circulates  less  rapidly,  or  is  even 
arrested  in  an  inflamed  part;  if  it  is  proved,  on  the  other  hand,  that  the  blood 
has  a tendency  to  become  dark  when  the  circulation  is  languid  or  suspended,  it 
will  not  seem  unreasonable  to  explain  in  this  way  the  brown  colour  of  the  mucous 
membrane  of  the  stomach  in  certain  cases  of  gastritis.  But  why  was  it  observed, 
as  I said  awhile  ago,  only  in  the  two  extremes,  in  super-acute  inflammation, 
and  in  chronic  inflammation?  It  is  for  this  precise  reason,  because  in  these  two 
extremes  stagnation  of  the  blood  more  or  less  complete  must  take  place,  princi- 
pally in  the  gastric  mucous  membrane.  Thus,  in  super-acute  inflammation, 
from  the  extreme  and  sudden  dilatation  of  the  vessels  considerable  embarrass- 
ment of  the  circulation  must  result,  a sort  of  strangulation,  the  effect  of  which 
will  be  obstruction  of  the  capillaries  ; and  then,  consecutively  to  this  obstruction, 
the  coagulation  of  the  blood  can  be  observed  in  the  artery  which  goes  to  the 
inflamed  part,  in  the  same  way  as  the  blood  is  seen  to  coagulate  in  a vein  below 
the  place  where  the  vessel  is  compressed.  Thence  the  termination  of  the  inflam- 
mation in  gangrene  may  be  the  result;  in  this  latter  termination,  accordingly, 
the  coagulation  of  the  blood  in  the  arteries  has  been  frequently  observed,  but 
this  coagulation  was  considered  as  consecutive  to  the  gangrene,  whilst,  from 
what  has  been  now  stated,  I should  be  disposed,  on  the  contrary,  to  think  that 
the  coagulation  of  the  blood  in  the  artery  precedes  this  gangrene,  and  that  the 
latter  phenomenon  is  but  the  necessary  result  of  it. 

In  chronic  inflammation  there  will  no  longer  be  a complete  stagnation  of  the 
blood,  as  in  the  super-acute  inflammation  just  mentioned;  in  this  chronic 


DISEASES  OF  THE  ABDOMEN. 


229 


inflammation  also  the  mucous  membrane  will  not  present  so  black  a colou,  but 
only  a grey-slate  or  brown  colour,  which  will  itself  be  more  or  less  striking,  ac- 
cording to  the  greater  or  less  retardation  of  the  circulation  of  the  blood.  Now 
it  seems  this  retardation  must  exist  every  time  the  vessels  of  the  inflamed  part 
have  undergone  considerable  dilatation  : a dilatation  which  should  be  particularly 
marked  in  cases  of  chronic  inflammation.  This  retardation  of  the  blood  in  a 
part  whose  capillary  vessels  have  been  considerably  dilated  is  the  result  of  that 
law  of  hydro-dynamics,  in  virtue  of  which  the  course  of  any  liquid  whatsoever 
must  be  retarded,  when  flowing  on  in  full  tubes  it  passes  from  a narrower  into 
a broader  part ; this  is  one  of  the  causes  why  in  the  normal  state  the  blood  cir- 
culates less  rapidly  in  the  capillaries ; we  may  readily  conceive  then,  that  it 
will  circulate  more  slowly  if  the  diameter  of  these  numberless  vessels  come  to 
be  accidentally  increased. 

The  dilatation  ^f  the  vessels  may  also  continue  after  the  inflammation  has 
ceased,  and  with  it  the  brown  colour  must  also  continue.  Indeed,  independently 
of  all  explanation,  it  seems  that  in  some  cases  this  colour  continues  in  a part 
formerly  inflamed,  but  which  is  no  longer  so.  There  can  be  no  doubt  of  this 
with  respect  to  the  skin  ; we  frequently  see  the  skin  around  ulcers,  which  have 
cicatrized,  and  have  been  for  a long  time  perfectly  healed,  still  retain,  to  a 
greater  or  less  extent,  the  more  or  less  deep  brown  red  colour.  Analogy  seems 
to  lead  us  to  admit,  that  in  some  cases,  that  which  takes  place  in  the  skin,  may 
also  take  place  for  certain  portions  of  mucous  membrane,  and  particularly  the 
gastric  mucous  membrane. 

It  is  at  present  so  generally  admitted  that  the  different  colours  now  mentioned 
are  the  result  of  inflammation,  and  particularly  of  chronic  inflammation,  that  I 
do  not  consider  it  necessary  to  dwell  on  the  proof.  However,  if  any  persons 
could  still  doubt  that  the  slate  colour,  or  the  brown  or  blackish  tints  of  the  inter- 
nal surface  of  the  stomach  indicates  a chronic  inflammation  of  this  organ,  I would 
submit  the  following  facts  to  their  consideration. 

First.  If  the  symptoms  manifested  during  life  by  those  persons  whose  stomach 
presents  after  death  one  of  the  tints  now  in  question,  be  carefully  observed,  it 
will  be  found  invariably  that  these  persons  have  had  symptoms  of  chronic  gas- 
tritis ; such  at  least  is  the  result  of  a great  number  of  cases  collected  by  me  at 
the  Cfiarite.  But  it  frequently  happens  that  these  symptoms  escape  an  inat- 
tentive examination,  either  because  they  are  really  but  little  striking,  or  particu- 
larly because  chronic  gastritis  frequently  comes  on  only  as  a complication  of 
another  disease,  which  engages  attention  more  or  less  exclusively.  It  has,  per- 
haps, been  too  often  said,  that  organic  lesions,  more  or  less  severe,  could  exist 
without  producing  any  symptoms.  But  how  many  of  these  lesions  might  have 
ceased  to  be  latent,  if,  during  life,  all  the  functions  had  been  the  object  of  a 
scrupulous  and  patient  examination  ! 

Secondly.  In  the  majority  of  cases,  at  the  same  time  that  the  colour  of  the 
mucous  membrane  has  undergone  one  of  the  modifications  pointed  out,  it  also 
presents  other  changes,  which  cannot  be  denied  to  be  the  results  of  inflammation: 
thus  it  is  thickened,  hard,  covered  with  vegetations,  etc.;  beneath  it  the  other 
coats  of  the  stomach  also  present  occasionally  traces  of  inflammation,  more  or 
less  intense.  If  the  co-existence  of  these  different  alterations  and  of  the  brown 
colour  of  the  mucous  membrane  is  the  most  general  case  ; if,  on'the  contrary, 
this  change  of  colour,  without  any  other  lesion,  is  much  less  frequently  observed, 
we  shall  naturally  be  inclined  to  admit  by  analogy  that,  even  when  it  exists  alone, 
it  is  the  result  then  also  of  an  inflammatory  process. 

Thirdly.  In  certain  cases  of  ulceration  of  the  stomach,  and  more  frequently 
in  ulceration  of  the  rest  of  the  intestinal  canal,  the  edges  of  these  ulcers  are  found 
to  be  either  of  a grev-slate  colour,  or  of  a more  or  less  dark  brown.  Now  where 
an  ulceration  exists,  the  existence  of  inflammation  cannot  be  questioned.  If  the 
20 


230 


ANDRAL’S  MEDICAL  CLINIC. 


brown  colour  of  the  edges  of  the  ulcer  depended  on  any  other  cause  than  inflam- 
mation, why  should  it  exist  only  around  the  ulceration  ? Why  should  we  see 
it  decrease  and  disappear  in  the  intervals  between  the  ulcerations?  Again;  you 
will  find  this  same  brown  or  black  tint  colouring  the  edges  of  some  ulcerations 
of  arteries;  and  here,  as  in  the  digestive  canal,  you  will  see  the  change  of  colour 
occupy  only  the  circumference  of  the  ulcerations,  and  between  them  the  inner 
surface  of  the  artery  will  resume  its  white  colour. 

Fourthly.  It  is  not  to  putrefaction  that  the  slate-colour,  brown  tinge,  etc.,  of 
the  mucous  membrane  of  the  stomach  can  be  attributed  ; for  more  than  once  I 
have  opened  bodies  in  different  degrees  of  putrefaction,  and  found  the  internal 
surface  of  the  stomach  and  intestines  presenting  a livid  red  tint,  either  uniformly 
diffused,  or  arranged  in  patches,  striae,  or  bands.  This  reddish  tint  was  proba- 
bly the  result  of  the  transudation  of  the  colouring  matter  of  the  blood  through 
the  vascular  parietes,  similar  to  the  transudation  of  bile,  which  takes  place  more 
promptly  through  the  gall-bladder.  But  whatever  was  the  degree  of  putrefaction, 
whether  slightly  or  very  far  advanced,  I never  saw  any  tint  resembling  the  slate- 
colour  or  brown-colour  of  chronic  gastritis. 

It  has  been  stated  that  this  particular  tint  should  be  considered  in  the  majority 
of  cases  as  the  result  of  the  colouring  of  the  mucous  membrane  by  the  gases  con- 
tained in  the  stomach  or  intestines.  This  colouring  is  attributed  chiefly  to  sul- 
phuretted hydrogen  gast  but  in  the  stomach  where  the  existence  of  this  gas  has 
never  been  proved,  the  brown  colour  is  very  frequently  observed.  Besides,  there 
is  no  proof  that  sulphuretted  hydrogen,  or  any  other  gas,  possesses  the  property 
of  imparting  a brown  or  black  colour  to  the  animal  tissues. 

Until  a series  of  gases  have  been  inclosed  in  portions  of  the  intestines,  and 
trial  is  made  whether  these  portions  become  coloured  or  not,  the  assertion  in 
question  should  only  be  considered  as  a mere  supposition. 

The  brown  tint  which  the  mucous  membrane  of  the  stomach  presents  when  in 
a state  of  chronic  inflammation,  affords  numerous  varietes  with  respect  to  its 
arrangement  and  its  extent.  With  respect  to  its  arrangement,  it  is  sometimes 
found  circumscribed  within  a small  number  of  points,  forming  as  it  were  isolated 
spots,  which  may  be  round,  or  more  or  less  irregular.  In  the  interval  between 
these  grey,  brown,  or  black  spots,  the  mucous  membrane  may  remain  more  or 
less  white.  In  consequence  of  their  exact  circumscription  and  well  defined 
colour,  one  would  often  say,  that  where  these  spots  exist,  a drop  of  colouring 
matter,  more  or  less  brown,  was  deposited.  Sometimes  in  spots  of  this  kind 
there  is  perceived  merely  a uniform  tint;  sometimes  the  naked  eye,  or  by  means 
of  a lens,  discovers  that  they  are  formed  of  an  assemblage  of  vessels  of  an  infi- 
nitely small  diameter,  which  are  themselves  filled  with  black  blood.  These 
spots  constitute  so  many  small  inflammations,  circumscribed  like  the  red  spots, 
frequently  observed  in  cases  of  acute  gastritis. 

Instead  of  the  simple  spots  just  described,  the  mucous  membrane  may  present 
either  brown  patches  of  greater  or  less  breadth  or  bands,  striae  or  lines  of  the 
same  colour ; in  fine,  it  may  present  a uniformly  brown  or  blackish  tint  in  the 
fourth,  the  half,  or  even  over  the  entire,  of  its  extent. 

Anatomists  do  not  as  yet  seem  to  have  particularly  noticed  a variety  of  black 
colour  seldom  presented  by  the  stomach,  but  much  more  frequently  by  the  small 
intestine.  The  internal  surface  of  the  latter  then  seems  as  it  were  studded  with 
myriads  of  small  black  points  of  almost  microscopic  minuteness,  which,  accord- 
ing as  they  are  more  or  less  numerous,  may  give  a more  or  less  marked  black 
tint  to  the  entire  intestinal  surface.  These  black  points  are  very  different  in 
their  appearance  from  another  species  of  black  points,  separate  or  aggregate, 
long  since  noticed  by  Peyer,  and  which  appertain  to  follicles.  If  we  examine 
those  in  question  with  the  lens,  we  see  that  they  occupy  the  summit,  and  more 
rarely  the  entire  extent  of  filaments  or  plates,  which  are  nothing  else  but  the 


DISEASES  OF  THE  ABDOMEN. 


231 


intestinal  villi.  It  is  clear  that  if  this  species  of  black  points  be  met  with  less 
frequently  in  the  stomach  than  in  the  small  intestines,  it  is,  because  in  the  stomach 
the  villi  are  less  marked  and  less  numerous.  By  an  attentive  examination  with 
the  lens,  the  intestine  being  covered  with  a thin  layer  of  water,  we  may  satisfy 
ourselves  that  these  myriads  of  black  points,  are  the  result  of  a very  fine  vascular 
injection  of  the  intestinal  villi.  Some  facts  induce  me  to  think,  that  the  black 
injection  of  these  villi,  which  renders  them  so  apparent,  is  most  frequently  con- 
nected with  a state  of  chronic  inflammation  of  the  small  intestine.  In  several 
cases  of  diarrhoea  of  long  standing,  I found  no  other  alteration  than  such  a colour 
in  the  intestines. 

If  in  all  cases  of  chronic  gastritis  the  colour  of  the  mucous  membrane  presented 
itself  as  it  has  been  now  described,  one  might  always  discover,  by  merely  in- 
specting the  stomach,  whether  the  inflammation  took  on  an  acute  or  chronic 
course,  since  we  have  seen  that  it  is  in  a very  small  number  of  cases  of  super- 
acute gastritis,  such  as  those  produced  by  poisoning,  that  the  mucous  membrane 
presents  a more  or  less  deep  brown  colour,  and  with  the  exception  of  these  very 
rare  cases,  the  brown  colour  indicates  a chronic  gastritis.  But  what  is  very  im- 
portant to  know,  is,  that  very  often  when  the  stomach  is  in  a state  of  chronic 
inflammation,  its  mucous  membraneis  neither  slate-coloured,  nor  brown,  nor 
black,  but  presents  a red  colour,  more  or  less  perfectly  similar  to  the  red  colour 
of  acute  inflammation.  Very  recently  we  opened  in  the  Charite  the  body  of  a 
young  man,  who  for  upwards  of  eight  months  before  his  death  presented  all  the 
symptoms  of  chronic  gastritis,  such  as  vomiting,  sense  of  weight  in  the  epigas- 
trium after  taking  food,  complete  anorexia  ; the  state  of  the  tongue  moreover 
was  natural,  a circumstance  as  common  in  chronic  gastritis  as  it  is  uncommon 
in  acute  gastritis.  In  this  individual  the  mucous  membrane  of  the  stomach 
was  found  to  be  of  a bright  red  colour  over  a great  part  of  its  extent.  In  other 
individuals,  who  had  presented  the  same  symptoms,  I found  a brown  colouring 
of  the  entire  mucous  membrane.  One  of  the  most  prominent  symptoms, 
vomiting,  may  also  be  absent,  both  in  the  case  of  red  colouring  and  that  of 
brown  colouring.  We  do  not  mean  to  lay  it  down  that  gastritis,  with  bright 
redness  of  the  mucous  membrane,  is  an  acute  inflammation  prolonged  to  an  in- 
definite length,  and  that  in  really  chronic  inflammation  there  is  a brown  colour- 
ing of  this  membrane.  We  know  that  in  both  cases  the  same  symptoms  may 
manifest  themselves ; but  it  is  very  possible  that  in  these  two  cases  the  treat- 
ment should  be  different.  We  think  that  in  the  former  case,  however  long  the 
disease  may  have  existed,  means  exclusively  antiphlogistic,  and  a mild  regimen, 
are  alone  suitable ; whilst  the  second  case,  on  the  contrary,  is  probably  one  of 
those  in  which  it  may  be  well  to  have  recourse  both  to  medicinal  substances  of 
a more  or  less  stimulating  nature,  and  to  a less  mild  regimen. 

Should  we  again  refer  to  a chronic  inflammation  of  the  stomach  another  shade 
of  colour  of  its  mucous  membrane,  \n  which  this  tissue,  instead  of  being  either 
red  or  brown,  is  on  the  contrary  of  a dull  white,  milk-like  colour,  a colour 
widely  different  from  the  species  of  white  tint,  which  seems  to  constitute  its 
normal  state  ? I think  we  should  still  refer  to  a chronic  gastritis  this  remark- 
able modification  of  the  colour  of  the  mucous  membrane.  In  fact,  first  I have 
found  this  colour  always  combined  with  other  alterations  which  unequivocally 
indicated  the  existence  of  an  inflammation,  such  as  thickening  and  induration 
of  the  membrane;  secondly,  other  inflamed  tissues  also  present  a tint  of  a duller 
white  than  is  natural  to  them.  Such  is  the  case  of  the  thickened  and  indurated 
cellular  tissue  which  surrounds  old  ulcers  ; such  also  is  the  case  of  the  serous 
membranes  covered  by  membraniforin  productions,  which,  having  been  at  first 
soft  and  red,  have  gradually  become  indurated,  and  have  at  the  same  time  ac- 
quired a very  remarkable  milky  whiteness.  Who  has  not  seen  such  spots  or 


232 


ANDItAL’S  MEDICAL  CLINIC. 


white  patches  in  the  pericardium,  in  the  arachnoid,  or  in  the  .pleura  ? Observe 
carefully  through  what  stages  the  inflammation  has  passed,  in  order  to  produce 
this  unusual  whiteness  in  the  cellular  tissue  and  in  the  serous  membranes  ; you 
will  find  the  same  stages  and  degrees  in  inflammation  of  mucous  membranes; 
analogy  will  lead  you  then  to  admit,  that  in  this  last  tissue,  as  in  the  others,  the 
white  colour  of  a duller  character  than  in  the  normal  state  may  be  considered 
as  a result  of  inflammation. 

Thirdly.  Again,  in  persons  who  had  presented  all  the  symptoms  of  the  best 
defined  chronic  gastritis,  the  stomach  has  presented  no  other  remarkable  lesion 
except  large  patches,  in  which  the  mucous  membrane  was  harder  and  thicker, 
and  at  the  same  time  of  an  evidently  duller  white  than  in  the  rest  of  its  extent. 
In  one  case  particularly,  recently  observed  at  the  Charite,  the  local  and  general 
symptoms  were  so  marked,  that  we  actually  believed  the  case  to  be  one  of  what 
is  called  a cancerous  affection  of  the  stomach  ; the  patient  had  several  times 
vomited  black  matter,  resembling  coffee-grounds.  Well  ! the  stomach  presented 
nothing  but  a milky  white  patch  towards  its  centre,  a little  broader  than  the 
palm  of  the  hand,  with  hardening  and  manifest  thickening  of  the  mucous  mem- 
brane, in  that  part  only  where  this  unusual  white  tint  existed.  This  tint  was, 
moreover,  marked  in  several  points  by  red  spots,  the  result  of  partial  vascular 
injeclions  ; and  further,  in  every  part  where  this  same  milky  tint  existed,  the 
mucous  membrane  was  covered  by  a membraniform  layer,  of  a dull  white  colour 
like  itself,  a species  of  exudation  almost  solidified,  bearing  some  resemblance 
to  the  epidermis,  which  terminates  around  the  cardia,  when  this  epidermis, 
thicker  than  usual,  forms  a contrast  by  its  whiteness  and  its  inorganic  appear- 
ance with  the  mucous  membrane  of  the  stomach,  which  beneath  it  becomes 
continuous  with  that  of  the  oesophagus. 

At  other  times,  the  milky  white  tint  which  we  are  now  considering,  coincides 
with  a state  of  puffiness  and  softeningof  the  mucous  membrane;  it  is  as  it  were 
furrowed  with  vessels  ; red  spots  are  observed  on  it : this  state  strongly  resem- 
bles that  which  has  been  described  by  anatomists  under  the  name  of  soft  cancer 
of  the  mucous  membranes  ; it  is,  in  my  opinion,  only  one  of  the  infinitely  vary- 
ing modifications  which  chronic  inflammation  may  cause  the  mucous  membrane 
of  the  stomach  to  undergo.  This  assertion  appears  to  me  the  legitimate  con- 
sequence of  the  facts  already  stated. 

In  almost  all  cases  wherein  the  stomach  has  been  the  seat  of  an  inflammation 
of  long  duration,  post-mortem,  examination  proves  that  the  consistence  of  the 
mucous  membrane  has  undergone  more  or  less  perceptible  modification. 
Sometimes  this  consistence  is  increased ; sometimes,  on  the  contrary,  it  has 
suffered  considerable  diminution  : in  the  former  case  there  is  induration , and 
in  the  latter  softening  of  the  membrane. 

Induration  of  the  mucous  membrane  of  the  stomach  is  one  of  the  best  ana- 
tomical characters  by  the  help  of  which  chronic  gastritis  may  be  distinguished 
from  acute  gastritis  ; and  what  we  say  here  with  respect  to  the  inner  coat  of  the 
stomach,  may  apply  to  all  the  membranous  or  parenchymatous  tissues.  In  all 
acute  inflammation  produces  several  lesions,  which  do  not  differ  from  those  to 
which  chronic  inflammation  may  also  give  rise.  Thus,  for  instance,  in  mucous 
membranes  softening  may  be  observed,  whether  the  inflammation  has  proceeded 
slowly  or  rapidly.  Induration,  on  the  contrary,  belongs  exclusively  to  chronic 
inflammation. 

Induration  of  the  gastric  mucous  membrane  may  be  general  or  partial  : — 

It  may  exist,  first,  with  the  natural  colour  of  the  membrane,  as  is  observed 
in  the  case  of  old  inflammation  of  the  skin  or  cellular  tissue  ; secondly,  with 
the  mucous  membrane  of  a duller  white  than  exists  in  the  normal  state  ; we  have 
already  noticed  this  case ; thirdly,  with  a greyish  colour,  or  a more  or  less  deep 


DISEASES  OF  THE  ABDOMEN. 


233 


brown  colour.  I have  never  seen  induration,  which  we  must  not  confound 
with  simple  thickening,  accompanied  by  a bright  red  colour  of  the  mucous 
membrane. 

Induration  of  the  mucous  membrane  of  the  stomach,  though  common  enough* 
is  observed  still  less  frequently  than  its  softening.  The  latter  is  unquestionably 
one  of  the  most  frequent  changes  observed  in  the  stomach  of  individuals  who 
die  in  the  hospitals  of  different  chronic  diseases.  If  then,  as  I have  elsewhere 
endeavoured  to  prove,  softening  of  the  mucous  membrane  of  the  stomach  is 
often  the  result  of  its  inflammation,  we  must  conclude  from  this,  that  gastritis, 
whether  acute  or  chronic,  is  a very  frequent  disease ; whether  it  exists  as  a 
principal  affection,  or  comes  on  only  consecutively,  and  as  a complication. 

Considered  in  reference  to  its  thickness,  the  mucous  membrane  of  the  sto- 
mach, when  in  a state  of  chronic  inflammation,  may  present  itself  under  three 
forms ; first,  it  may  have  retained  its  natural  thickness  ; secondly,  the  thickness 
may  be  more  or  less  perceptibly  increased  ; thirdly,  instead  of  an  increase  of 
'thickness,  the  mucous  membrane  may  be  attenuated.  Let  us  examine  these 
three  states  in  succession. 

We  have  scarcely  any  thing  to  say  regarding  the  first  state,  that  in  which  the 
mucous  membrane  is  not  either  perceptibly  increased  nor  diminished  in  thick- 
ness. This  case  is  by  no  means  very  uncommon.  At  the  same  time  the  mu- 
cous membrane  is  found  either  simply  red  or  brown,  or  presenting  different 
colours  at  one  and  the  same  time,  and  more  or  less  softened. 

The  increase  in  the  thickness  of  the  mucous  membrane  is  very  frequent  in 
cases  of  chronic  inflammation.  It  may  exist  either  with  a state  of  softening  of 
the  membrane,  or,  on  the  contrary,  with  its  induration.  In  the  former  case, 
the  increase  in  thickness  is  in  some  measure  only  apparent ; the  membrane  is 
tumefied,  puffed,  swollen,  as  it  were,  by  the  liquids  which  flow  to  it  from  all 
parts  under  the  influence  of  the  inflammatory  stimulus  : thus  the  reticulated 
tissue  of  the  skin  becomes  swollen,  where  a blister  is  applied.  This  tume- 
faction of  the  gastric  mucous  membrane  with  softening,  is  observed  more  fre- 
quently in  acute  than  in  chronic  gastritis  ; yet  it  sometimes  exists  also  in  this 
latter  case.  On  the  contrary,  the  increased  thickness,  with  induration,  exists 
only  in  chronic  gastritis,  and  is  one  of  its  least  equivocal  signs.  There  is,  in 
this  case,  a real  increase  of  density,  true  hypertrophy  of  the  mucous  mem- 
brane. This  is  the  natural  consequence  of  the  more  active  nutrition  of  which 
this  membrane  must  necessarily  become  the  seat  when,  having  been  for  a long 
time  the  seat  of  inflammation,  it  receives  a greater  quantity  of  blood  than  in  its 
healthy  state.  As  long  as  this  hypertrophy  alone  takes  place,  it  may  be  said 
that  the  inflammation  has  only  given  an  excess  of  activity  to  the  nutrition  of 
the  mucous  membrane,  nearly  in  the  same  way  that  exercise  occasions  hyper- 
trophy of  a muscle;  but  then,  the  laws  of  nutrition  are  still  the  same  as  those 
which  existed  in  the  natural  state.  If,  on  the  contrary,  instead  of  this  simple 
hypertrophy,  the  gastric  mucous  membrane  present  the  appearance  of  softening 
— if  it  be  ulcerated  — if  its  tissue  is  transformed  into  new  tissues  — then  we 
must  no  longer  merely  admit  an  excess  of  activity  of  the  phenomena  of  nutri- 
tion ; but  it  must  be  observed,  that  the  laws  which  preside  over  the  production 
of  these  phenomena  have  undergone  a change,  and  a real  perversion.  It  is, 
moreover,  very  important  to  remark,  that  one  or  other  of  these  effects,  namely, 
mere  increase  in  the  activity  of  nutrition,  or  the  perversion  of  this  function, 
does  not  seem  to  be  directly  proportioned  to  the  intensity  of  the  inflammation. 
When  violent,  and  of  very  long  duration,  it  may  occasion  only  simple  hyper- 
trophy of  the  tissue  which  it  has  attacked,  apparently  very  slight ; it  may 
modify,  and  seriously  pervert  the  laws  of  nutrition,  and  so  produce  disorgani- 
sations, and  degenerations  of  the  most  varied  character. 

Whether  the  thickening  of  the  gastric  mucous  membrane  coincides  with  its 
20* 


234 


ANDRAL’S  MEDICAL  CLINIC. 


softening  or  its  induration,  it  may  have  at  once  attacked  a great  extent  of  this 
membrane,  or  occupy  only  some  circumscribed  points  of  it.  These  separate 
partial  thickenings  may  be  scarcely  perceptible  to  the  sight,  and  appreciable 
only  when  the  membrane  has  been  detached.  But  at  other  times  they  are 
much  more  considerable.  The  result  may  be  exanthemes,  vegetations,  tumours 
which  present  infinite  varieties  with  respect  to  their  form,  their  texture,  their 
size,  their  number,  and  their  situation. 

I shall  not  dwell  on  a description  of  the  very  different  and  strange  forms 
which  these  tumours  may  assume  ; but  I shall  observe,  that  very  often  it  is 
solely  in  consequence  of  such  or  such  a form  that  persons  have  considered 
themselves  warranted  in  constituting  distinct  and  particular  diseases  of  several 
of  these  tumours,  and  that  many  are  accustomed,  without  further  examination, 
to  separate  their  description  of  the  history  of  chronic  gastritis,  as  if  a mere  modi- 
fication of  form  could  establish  a real  difference  between  diseases  similar  in  all 
other  respects.  Neither  need  I trouble  myself  with  the  differences  in  the  size 
of  these  tumours,  or  with  their  varieties  in  point  of  number.  These  details  are 
to  be  found  everywhere  ; these  differences,  like  those  of  form,  are  but  acciden- 
tal, and  can  no  more  serve  than  the  latter  to  distinguish  the  nature  of  the  dis- 
ease. To  attain  this  latter  end,  it  will  be  necessary  to  study  particularly  their 
mode  of  development  and  their  texture. 

Considered  with  respect  to  their  texture,  or  their  anatomical  composition,  if 
I may  to  say,  the  tumours  developed  on  the  inner  surface  of  the  mucous  mem- 
brane of  the  stomach,  and  which  seem  to  be  nothing  but  a morbid  expansion  of 
this  membrane,  may  be  divided  into  two  classes.  Under  the  first  may  be  ranked 
all  those  tumours,  vegetations,  etc.,  whose  texture  represents  accurately  the 
texture  of  the  mucous  membrane,  either  indurated  or  in  different  degrees  of 
softening;  in  the  second  class  we  shall  place  those  tumours  whose  apparent 
texture  no  longer  seems  to  have  any  resemblance  to  the  texture  of  the  mucous 
membrane,  whether  in  the  healthy  or  morbid  state.  The  former  class  of 
tumours  seems  to  me  to  be  that  most  frequently  observed ; and  if  it  is  proved 
that  induration  and  softening  of  the  gastric  mucous  membrane  are  a result  of  its 
inflammation,  these  same  alterations  should  also  be  connected  with  the  latter, 
where  they  are  circumscribed,  and  possess  sufficient  thickness  to  form  tumours. 
It  is  manifest  that  this  mere  change  of  form  cannot  induce  a change  in  the  nature 
of  the  disease.  No  controversy  can  exist  then  except  for  the  second  class  of 
tumours,  whose  texture  no  longer  appears  to  be  that  of  the  mucous  membrane, 
whether  in  its  healthy  state  or  in  different  degrees  of  inflammation.  Thus, 
among  partial  thickenings  of  this  membrane,  several  are  formed  of  a hard  homo- 
geneous tissue,  of  a dull  white  colour,  furrowed  or  not  by  vessels.  Others 
constitute  vegetations,  fungous  growths,  either  pediculated  or  connected  by  a 
broad  base  with  the  rest  of  the  mucous  membrane,  and  formed  by  a soft  whitish 
or  reddish  tissue,  resembling  cerebral  parenchyma,  which  is  putrefied.  This 
encephaloid  tissue,  so  admirably  described  by  Laennec,  indicates  evidently  a 
remarkable  modification  of  texture  in  the  mucous  membrane.  But,  if  the  de- 
velopment of  this  encephaloid  tissue  in  the  stomach  is  preceded  by  the  same 
causes  as  those  which  give  rise  to  chronic  gastritis;  if  its  presence  is  indicated 
by  the  same  symptoms  ; if,  in  a great  number  of  cases,  it  tends  to  become  con- 
founded, in  reference  to  anatomical  structure,  with  other  changes  which  are  the 
unquestionable  result  of  inflammation  ; if,  too,  it  must  be  combated  by  the  same 
mode  of  treatment  — it  wifi,  I think,  be  reasonable  to  conclude,  that  the  ence- 
phaloid tissue  developed  in  the  gastric  mucous  membrane  is  the  result  of  an 
inflammatory  process.  In  making  this  assertion,  I do  not  mean  to  say,  that 
wherever  the  encephaloid  tissue  appears,  inflammation  has  necessarily  given 
rise  to  it.  I think  that,  in  the  present  state  of  science,  we  do  not  as  yet.  possess 
sufficient  data  to  establish  such  a fact.  There  are  some  tissues  and  organs  in 


DISEASES  OF  THE  ABDOMEN. 


235 


which  it  would  be  impossible  to  prove,  except  by  an  analogy  which  might  be 
fallacious,  that  the  different  accidental  tissues  were  produced  by  inflammation; 
and,  moreover,  in  all  cases  this  inflammation  can  concur  in  their  production  only 
as  an  occasional  cause,  if  there  be  a predisposition. 

The  situation  of  tumours  of  the  mucous  membrane,  in  such  or  such  a part  of 
the  stomach,  is  far  from  being  indifferent,  since  the  greatest  varieties  may  re- 
sult in  the  symptoms  from  one  or  other  of  these  situations.  Who  does  not 
know  how  far  from  bearing  any  resemblance  to  each  other,  are  the  phenomena 
which  manifest  themselves  when  the  vegetation  occupies  the  parts  around  the 
oardia,  which  it  obliterates  more  or  less  completely,  when  it  occupies  the  pylo- 
rus, or  when  it  exists  only  in  one  or  other  surface  of  the  stomach  ? 

Lastly,  there  are  some  cases  where  the  gastric  mucous  membrane,  instead  of 
being  thickened  or  hypertrophied,  is  thinner  than  in  its  normal  state,  and  has 
undergone  a real  atrophy;,  it  is  principally  towards  the  great  cul-de-sac  that 
this  latter  state  is  met  with,  where  softening  also  is  most  frequently  observed. 
Sometimes,  however,  I have  found  the  mucous  membrane  towards  the  pylorus 
so  attenuated,  that  it  now  resembled  a sort  of  transparent  extremely  fine  web. 
On  attempting  to  raise  it,  it  was  changed  into  a reddish  white  pulp,  as  happens 
in  certain  degrees  of  softening.  Should  atrophy  of  the  mucous  membrane  of 
the  stomach,  like  its  hypertrophy,  and  softening  without  diminution  in  thick- 
ness, be  classed  among  the  products  of  inflammation?  At  least,  it  is  certain 
that,  on  the  one  hand,  this  atrophy,  which  seems  to  be  but  a form  of  softening  of 
the  mucous  membrane,  most  usually  accompanies  other  anatomical  signs  of 
chronic  gastritis;  and  that,  on  the  other  hand,  the  symptoms  observed  during 
life  are  entirely  similar  to  those  which  announce  gastritis.*  A woman,  thirty- 
six  years  of  age,  died  in  the  Charite  in  the  month  of  March  ; during  the  three 
last  days  of  her  life  she  had  frequent  vomiting.  The  stomach  presented  seve- 
ral red  patches  in  different  points  of  its  extent ; still  farther,  in  the  splenic  por- 
tion, both  over  the  red  patches  themselves  and  in  the  intervals  between  them, 
the  mucous  membrane  was  softened,  and  at  the  same  time  so  attenuated  as  not 
to  equal  in  thickness  the  mucous  membrane  of  the  maxillary  sinus. 

However,  it  would  not  seem  to  me  unreasonable  to  admit,  that,  in  some  cases, 
attenuation  of  the  gastric  mucous  membrane  results  from  mere  atrophy,  which 
is  no  more  preceded  by  inflammation  than  the  latter  phenomenon  precedes  the 
atrophy  of  the  muscles  in  phthisical  patients.  I have  observed  such  an  attenua- 
tion in  some  individuals  labouring  under  chronic  affections  of  the  lung  : in  them 
it  was  not  the  mucous  membrane  only,  but  the  muscular  tunic  also,  which  was 
considerably  atrophied. 

Ulcerations  of  the  gastric  mucous  membrane  are  much  more  uncommon  than 
of  the  mucous  membrane  of  the  termination  of  the  small  and  large  intestine. 
However,  with  respect  to  the  frequency  of  these  ulcerations,  a difference  must 
be  established  between  acute  and  chronic  gastritis.  In  the  former,  unless  it  be 
the  result  of  the  introduction  of  corrosive  poisons  into  the  stomach,  ulceration  is 
a phenomenon  extremely  rare.  On  the  contrary,  in  the  case  of  chronic  inflam- 
mation of  the  stomach,  the  gastric  mucous  membrane  is  often  found  ulcerated; 
then  this  ulceration  is  most  frequently  single,  and  of  greater  or  less  diameter. 
Around  it  the  mucous  membrane  may  be  healthy  or  diseased.  The  same  may 
be  said  of  the  cellular  membrane,  which  constitutes  the  bottom  of  the  ulcer. 
When  the  latter  consists  of  the  cellular  tissue  considerably  indurated,  and  when, 
at  the  same  time,  the  portion  of  mucous  membrane  which  exists  around  the 
ulceration  is  thickened,  puffy,  and,  as  it  were,  fungous,  and  traversed  by  numer- 
ous vessels  ; when  shreds  of  inflamed  mucous  membrane,  to  greater  or  less  ex- 

* We  must  not,  however,  forget  that  similar  symptoms  may  he  the  result  of  lesions  of  dif- 
ferent kinds,  and  which  require  a very  different  treatment. 


236 


ANDRAL’S  MEDICAL  CLINIC. 


tent,  are  found  on  the  bottom  of  the  ulcer,  under  the  form  of  vegetation,  some 
physicians  call  this  alteration  a cancer  of  the  mucous  membrane  which  has  ter- 
minated in  ulceration.  Is  this  a suitable  expression  ? I shall  discuss  this  point 
more  in  detail  after  having  treated  of  the  other  coats  of  the  stomach. 

We  shall  not  here  refer  to  those  cases  mentioned  in  every  work  in  which  deep 
ulcerations  of  the  stomach  are  observed  to  terminate  in  perforation  of  this  organ 
— we  shall  not  here  refer  to  the  circumstance  that,  in  several  patients,  there  is 
then  effusion  into  the  peritoneum  of  the  matters  contained  in  the  stomach, 
whilst  in  others,  where  the  parietes  of  the  stomach  no  longer  exist,  the  bottom 
of  the  ulcer  is  formed  by  the  liver,  the  spleen,  and  the  pancreas,  which  adhere 
to  its  circumference,  and  prevent  any  effusion  into  the  peritoneal  cavity.  Here, 
however,  we  shall  state  a fact  which  is  remarkable  for  the  circumstances  which 
preceded  the  perforation,  and  for  the  nature  as  well  as  the  number  of  the  lesions 
which  existed  simultaneously  with  it.  We  shall  then  cite  the  case  of  another 
individual,  who  also  suffered  from  a cancerous  affection  of  the  stomach,  and 
who  presented  this  curious  circumstance,  that  in  him  the  stomach  was  perfo- 
rated during  an  effort  to  vomit,  and  at  a distance  from  the  point  where  the  cancer 
existed. 

Case  1. — Communication  between  the  cavity  of  a cancerous  stomach,  with  the  interior  of  the 

lung  in  a state  of  gangrene,  through  an  opening  which  involved  the  pleura,  diaphragm,  and 

spleen  which  was  in  a great  measure  destroyed. — During  life,  signs  of  pneumothorax,  and 

of  an  old  affection  of  the  stomach. 

A tailor,  forty  years  of  age,  a native  of  Bavaria,  of  a lymphatico-sanguineous 
constitution,  with  hair,  eyebrows,  and  beard  of  a brown  colour,  blue  eyes, 
complexion  not  high  coloured,  still  not  pale-,  five  feet  in  height.  Had  small 
umbilical  hernia  of  long  standing.  His  father  and  mother  were  healthy,  and 
still  alive.  He  states  that  he  never  had  been  subject  to  chest  affections,  and 
that  he  had  always  enjoyed  good  health  up  to  the  close  of  1828,  when,  for  the 
first  time,  he  felt  frequently  very  ill  from  difficult  digestion  ; he  experienced 
alternately  a devouring  appetite  and  absolute  disgust  for  every  kind  of  food.  He 
had  been  in  France  since  1810,  and  had  constantly  lived  in  the  greatest  hard- 
ship, being  addicted  to  the  excessive  use  of  ardent  spirits.  He  had  had  nine 
attacks  of  syphilis  in  three  years,  and  generally  slept  in  the  open  air.  When 
sober,  however,  he  was  constantly  employed  at  his  trade,  he  being  a very  clever 
and  expert  workman,  as  his  master  told  me,  who  furnished  me  with  these  par- 
ticulars. 

It  appeared  that,  on  the  20th  of  August,  1829,  after  a violent  altercation  with 
some  comrades,  he  went  and  laid  down  in  an  unsheltered  place,  according  to  cus- 
tom, and  slept  there  for  three  hours.  When  he  awoke  he  was  extremely  cold,  and 
returned  home,  and  as  the  daylight  had  not  yet  appeared,  he  lay  down  on  a table, 
and  slept  till  morning.  On  awaking,  he  had  a violent  shivering,  an  acute  pain 
under  the  left  breast,  and  was  altogether  very  ill.  A little  after  dyspnoea  came 
on.  At  last,  towards  the  fourth  day,  he  expectorated  a great  quantity  of  yellow 
thick  sputa  (never  streaked),  and  not  having  any  remarkable  taste.  He  had 
violent  fits  of  coughing,  which  lasted,  without  ceasing,  for  more  than  half  a day. 
Fumigations  with  vinegar,  were  recommen  ded  for  the  pain  of  head.  He  took  some 
demulcent  drinks,  and  found  himself  somewhatrelieved  on  the  following  day.  The 
pain  and  cough  were  gone.  On  the  12th  September  he  entered  the  Charite,  the 
above-mentioned  symptoms  having  increased  considerably  in  the  course  of  a few 
hours  ; and  on  the  13th,  when  we  visited  him,  he  presented  the  following  symp- 
toms : — Countenance  pale,  emaciated,  and  expressive  of  distress  ; breath  very 
fetid  ; the  gums  red  and  excoriated  ; tongue  pale  and  moist.  The  patient  experi- 
enced extreme  difficulty  in  articulating  his  words  ; breathing  very  short ; there  was 
even  orthopncea  : extreme  debility  induced  him  to  lie  on  the  leftside,  but  he  was 


DISEASES  OF  THE  ABDOMEN. 


2 37 


soon  obliged  to  raise  himself  suddenly,  and  to  place  himself  in  a semi-recumbent 
posture,  resting  on  his  left  elbow.  The  chest  projected  on  the  left  side,  and  its  de- 
velopment was  such  that  the  intercostal  muscles  were  protruded  beyond  the  ribs. 
The  right  side  alone  moved  during  respiration,  and  the  motions  of  elevation  were 
perceptible  on  the  left  side  only  at  the  intervals  between  the  ribs.  The  vibration, 
which  was  nearly  absent  on  the  left  side,  was  very  perceptible  on  the  right.  The 
respiratory  murmur  wanting  on  the  left,  and  very  distinct  on  the  right  side. 
The  metallic  souffle  is  heard  occasionally  above  the  left  breast,  but  it  is  light 
and  intermittent.  On  the  left  there  is  a sonorousness  both  absolutely  and  rela- 
tively very  great.  On  the  right  the  sound  is  natural.  When  the  patient  sits  up, 
a position  in  which  he  is  able  to  remain  only  for  a few  moments,  the  phenomena 
in  the  posterior  part  of  the  chest  are  precisely  similar,  to  those  on  the  ante- 
rior. The  voice  is  resonant  and  amphoric  on  the  left ; it  is  natural  on  the  right. 
The  metallic  tinkling  is  perceived  to  be  but  very  slight;  this  may  be  attributed, 
no  doubt,  to  the  impossibility  of  auscultating  the  patient  in  a satisfactory  man- 
ner. Lastly,  the  cough  is  frequent,  the  respiration  panting;  the  expectoration, 
which  is  rather  considerable,  presents  diffluent  white  sputa,  not  frothy,  and 
mixed  with  light  flocculi  ; their  stench  is  suffocating.  (One  would  think  their 
odour  to  be  that  of  faeces  combined  with  that  of  gangrene.  We  shall  presently 
see  that  the  diagnosis  was  well  founded.)  Pulse  weak  and  frequent;  skin 
rather  colder  than  natural.  On  the  14th,  same  state  ; more  difficulty  in  the  re- 
spiration. On  the  15th,  the  patient  is  no  longer  able  to  rest ; every  position 
is  painful  to  him  ; the  orthopnoea  is  increased  since  yesterday  ; cough  violent; 
the  odour  of  the  sputa  extremely  fetid. 

On  the  16th,  for;  the  first  time,  we  were  able  to  examine  the  posterior  part  of 
the  thorax  satisfactorily  ; we  found  towards  the  inferior  angle  of  the  scapula  the 
metallic  tinkling  very  distinct,  the  respiration  amphoric,  the  voice  the  same,  the 
metallic  souffle  very  loud  during  inspiration.  This  point  is  painful.  On  the 
right  the  respiration  was  bronchial ; on  the  left  there  was  dulness  ; on  the  right 
sonorousness  ; just  the  contrary  anteriorly,  where  the  phenomena  remained 
similar  to  what  they  were  on  the  15th.  Pulse  frequent  and  small ; skin  cold  ; 
tongue  red  in  the  centre  and  edges,  and  presenting  some  white  spots  towards 
the  base.  Great  shortness  of  breath,  cough  less  frequent  than  yesterday;  or- 
thopncea  ; sputa  very  different  from  what  they  were  observed  to  be  the  preced- 
ing days,  being  now  viscid,  like  a thick  solution  of  gum,  and  mixed  with  white 
grains  about  the  size  of  a hemp-seed  ; their  odour  not  so  strong  as  on  the  pre- 
ceding evening.  This  night  the  patient  slept  a little  ; he  is  now  very  feeble  ; 
countenance  pale,  eyes  sunk;  the  alee  nasi  depressed  ; there  is  a great  appear- 
ance of  dejection  and  anxiety  ; voice  changed. 

On  the  17th  the  same  general  state ; sputa  contain  less  white  grains  than  on 
the  preceding  day,  their  odour  was  sourish  ; the  smell  from  the  patient  resem- 
bled that  which  comes  from  persons  in  whom,  after  amputation,  the  lung  has 
become  the  seat  of  suppuration.  He  can  now  lie  on  the  left  side. 

On  the  18th  there  was  great  dyspnoea  ; the  sputa  were  of  the  same  character, 
but  much  less  copious  ; but  little  cough  ; countenance  very  much  dejected  and 
pale  ; voice  very  weak,  and  articulation  very  difficult.  The  patient  slept  a little  ; 
he  sits  up,  embracing  his  knees  between  his  hands,  or  when  fatigued,  throws 
himself  on  his  left  side..  Pulse  ninety-five,  hard,  small,,  and  wiry  ; extremities 
cold  ; some  sweat  on  the  chest,  which  is  very  much  enlarged  on  the  left  side, 
very  sonorous,  presenting  no  vibration,  and  painful  ; the  intercostal  spaces  give 
to  the  touch  the  sensation  of  a bladder  full  of  air.  We  hear  only  the  metallic 
tinkling  and  resonance  of  the  voice  on  the  right ; respiration  puerile  ; dilatation 
not  much  marked ; respiration  almost  entirely  abdominal ; some  vibration  and 
some  pain  also,  but  less  severe  than  on  the  left  side.  No  diarrhoea,  three  stools 
at  most ; no  desire  for  drink  or  food  ; breath  sour. 


23S 


ANDRAL’S  MEDICAL  CLINIC. 


On  the  19th  the  state  of  the  patient  worse  in  every  respect.  The  metallic 
and  amphoric  murmurs  increased.  No  sputa;  but  little  cough  ; unable  to  arti- 
culate a single  word  ; cold,  clammy,  fetid,  sour  smell.  The  mucous  rale  usually 
indicating  the  approach  of  death  at  about  two  o’clock  in  the  afternoon ; died  at 
nine  o’clock  without  a moan. 

Post-mortem,  twenty-one  hours  after  death.  Great  emaciation  ; entire  body 
of  a dull  pale  colour;  considerable  enlargement  of  the  leftside  of  the  chest.  An 
incision  made  between  the  seventh  and  eighth  ribs  gave  exit  to  a quantity  of  air, 
sufficient  to  extinguish  and  again  to  light  a candle.  The  left  lung  was  pressed 
along  the  spine,  and  adhered  by  its  posterior  Surface  to  the  parietes  of  the  chest; 
superiorly  the  adhesions  were  of  long  standing,  and  inferiorly  they  were  recent. 
This  organ  was  become  carnified,  and  its  green  colour  was  not  owing  to  cada- 
veric decomposition.  The  cavity  was  half  filled  with  a liquid  somewhat  re- 
sembling whey,  in  which  whitish,  friable  clots  floated  like  cheese.  This  lung 
being  inflated  through  the  trachea,  presented  an  aperture  situated  towards  the 
middle  part  of  the  circumference  of  the  left  lobe  ; two  fingers  from  its  edge  the 
air  which  escaped  from  it  produced  bubbles,  which  burst  on  the  surface  of  the 
effused  liquid  ; lower  down,  this  edge  adhered  to  the  ribs  through  the  remainder 
of  its  extent,  and  on  destroying  this  connexion  a greyish  brown  eschar  was 
found  of  the  size  of  a filbert,  not  entirely  stopping  up  a second  aperture.  These 
two  openings  were  formed  on  the  outer  wall  of  a burrow  which  contained  some 
pulmonary  detritus,  and  communicated  by  means  of  adhesion  and  subsequent 
suppuration  with  the  great  cul-de-sac  of  the  stomach  ; the  aperture  was  capable 
of  admitting  two  fingers.  This  latter  viscus  was  scirrhous  through  its-  entire 
cardiac  portion,  and  was  from  one  inch  to  eighteen  lines  thick  towards  the  per- 
foration. We  shall  speak  of  this  state  in  another  place. 

The  pleura  costalis  was  ulcerated  through  almost  its  entire  extent,  and  over 
those  points  not  adhering  to  the  lung ; it  exposed  to  view  the  internal  intercos- 
tals,  which  were  also  perforated  in  some  points  over  their  entire  surface.  The 
parietal  pleura  was  smooth  and  covered  with  a very  fine  pseudo-membrane, 
which  was  gangrenous  some  points,  and  which,  when  cut  into  perpendicularly, 
led  to  cavities  containing  a detritus  resembling  soot  diluted  in  water,  and 
also  gangrenous  pus  ; a very  characteristic  odour  was  exhaled  from  it ; it  re- 
sembled that  of  the  sputa  of  the  12th,  but  was  stronger  and  more  suffocating. 
These  cavities  were  large  enough  to  contain  a hemp-seed,  some  of  them  even 
a small  pea.  The  summit  of  the  lung  contained  some  cretaceous  masses,  de- 
posited in  the  traces  of  old  cavities  formerly  obliterated  ; their  great  hardness 
indicated  the  remote  period  of  their  formation. 

The  right  pleura  contained  only  a little  limpid  serum  ; here  and  there  it  was 
inflamed,  and  presented  a slate-coloured  tint ; on  some  points  only  it  was  covered 
by  false  membrane,  similar  to  that  on  the  left  side.  The  lung,  which  was  in  a 
great  measure  pervious  to  air,  was  covered  by  a tissue  resembling  that  on  the 
left  side,  but  not  continuous  ; it  was  deficient  principally  where  some  spots 
were  observed,  which  led,  as  on  the  left  side,  to  gangrenous  cavities  ; they 
were  more  common  on  this  side.  The  summit  of  the  upper  lobe  presented  an 
appearance  of  retraction,  and  some  rugae,  indicating  the  existence  of  former 
cavities.  When  incised  vertically  it  presented  cretaceous  masses,  as  on  the 
leTt.  The  pericardium  was  red  to  about  one-third  of  its  extent  on  the  left ; on 
the  right  there  were  some  arborisations.  The  heart  presented  here  and  there 
some  whitish  patches.  It  was  not  large  in  size. 

The  diaphragm  on  the  left  side  was  visibly  altered  in  its  texture,  and  par- 
ticipated in  the  cancerous  degeneration  of  the  stomach  at  the  point  of  its  perfo- 
ration only  : at  a distance  from  that  it  was  intact,  and  presented  nothing  re- 
markable. 

The  stomach  contained  a liquid  like  to  that  of  the  left  thoracic  cavity  ; its 


DISEASES  OF  THE  ABDOMEN. 


239 


parieles  gradually  increased  in  thickness  from  the  pylorus,  which  was  intact  to 
the  great  cul-de-sac,  which  was  perforated,  as  has  been  already  mentioned. 
Its  substance  was  indurated  and  fatty,  its  colour  was  white,  more  particularly 
at  the  part  occupied  by  the  muscular  coat,  which  appeared  to  be  a layer  distinct 
from  the  rest ; towards  the  small  curvature,  and  around  the  solution  of  conti- 
nuity, the  mucous  membrane  presented  numerous  fungous  growths,  the  vertical 
section  of  which  exposed  to  view  a white  tissue,  traversed  by  a very  small 
number  of  bloodvessels. 

The  spleen  was  gone  ; it  formed  the  centre  of  the  purulent  collection  formed 
through  the  diaphragm  ; its  parenchyma  might  still  be  recognised  in  its  almost 
natural  state  towards  the  two  extremities  of  its  great  diameter;  its  entire  centre 
was  reduced  to  a brownish  pulp,  and  formed  several  incomplete  septa,  which 
lay  transverse  to  the  axis  of  the  burrow. 

The  gastro-colic  epiploon  was  very  red,  and  presented  a multitude  of  miliary 
vegetations,  which  were  also  red  and  hard.  The  liver  was  large  and  very  yel- 
low, but  did  not  grease  the  scalpel.  The  ductus  choledochus  was  very  broad. 
The  kidneys  were  healthy  ; the  left  adhered  by  its  upper  extremity  to  the  cul- 
de-sac  of  the  stomach,  and  to  the  mass  formed  by  this  viscus,  the  spleen,  and 
the  diaphragm.  Its  suprarenal  capsule  no  longer  existed  ; it  was  found  on  the 
right,  where  it  was  large. 

The  intestines,  which  in  general  were  in  a state  of  inflammation,  were  covered 
with  a sero-purulent,  creamy  membrane ; the  lower  part  of  the  lesser  pelvis 
contained  some  spoonsful  of  a thick  purulent  liquid.  The  mesenteric  glands, 
and  chiefly  those  adhering  to  the  vertebral  column,  were  indurated  and  scirrhous. 

The  bladder  was  healthy ; the  urethra  bore  traces  of  a former  inflammation  ; 
the  mucous  membrane  was  ulcerated  in  different  points,  and  excoriated  towards 
the  free  orifice. 

Case  2. — Cancerous  ulcer  of  the  stomach ; bottom  of  the  ulcer  formed  by  the  pancreas — Per- 
foration of  the  parietes  of  the  stomach  during  an  effort  of  vomiting — Peritonitis. 

A copper-smith,  aged  sixty-four  years,  stated  that  he  was  tormented  the  last 
month  only  with  very  severe  abdominal  pains,  which  lasted  for  half  a day,  then 
left  him,  and  returned  in  a day  or  two. 

There  was  at  the  same  time  complete  loss  of  appetite,  nausea,  and  vomiting. 
The  introduction  of  food  into  the  stomach  increased,  or  even  brought  on  abdo- 
minal pains,  the  precise  seat  of  which  the  patient  did  not  fix  upon.  The  food 
was  most  frequently  partly  thrown  up,  some  time,  or  more  rarely  immediately 
after  it  had  been  swallowed.  The  patient  was  not  very  strictly  examined,  his 
trade  of  a copper-smith  having  inclined  us  to  think  that  his  symptoms  were 
attributable  to  metallic  emanations ; in  fact,  that  it  was  a case  of  lead  colic, 
accompanied  by  some  unusual  symptoms.  Consequently,  we  ordered  him 
four  grains  of  tartar  emetic  in  a glass  of  water ; a narcotic  lavement ; decoction 
of  prunes  sweetened  for  his  drink. 

He  vomited  very  much  after  having  taken  the  tartar  emetic,  and  had  copious 
evacuations  by  stool.  After  an  effort  to  vomit,  he  felt  the  sensation  as  if  a ball, 
commencing  at  the  epigastric  region,  had  descended  below  the  umbilicus.  From 
this  moment  all  the  symptoms  of  super-acute  peritonitis  made  their  appearance. 
He  died  the  following  day. 

Post-mortem. — Head  and  chest  perfectly  sound. 

Abdomen.  — A great  quantity  of  reddish  serum,  mixed  with  albuminous 
flocculi,  was  effused  in  the  abdomen.  The  peritoneal  coat  of  the  intestines 
presented  patches  of  a bright  red  colour  in  different  points.  The  mucous  mem- 
brane was  healthy. 

Stomach.  — On  the  anterior  aspect  of  this  viscus,  about  three  or  four  fingers 


240 


ANDllAL’S  MEDICAL  CLINIC. 


breadth  to  the  left  of  the  pylorus,  very  close  to  the  edge  of  the  diaphragm,  was 
observed  a perforation  large  enough  to  admit  the  extremity  of  the  little  finger. 
The  contents  of  the  stomach  were  no  doubt  effused  into  the  cavity  of  the  peri- 
toneum through  this  perforation,  which  was  occasioned  by  a rupture  of  the  dis- 
eased parietes  of  the  stomach  in  the  midst  of  the  efforts  made  to  vomit.  Thence 
the  peritonitis  ; the  sensation  of  the  ball  experienced  by  the  patient,  probably 
indicated  the  moment  when  this  effusion  had  taken  place.  An  incision  being 
made  into  the  stomach,  we  found  posteriorly,  and  more  to  the  left  than  the  per- 
foration of  the  anterior  wajl,  an  ulcer  nearly  three  or  four  times  as  large,  with 
thick  raised  edges,  irregular  in  its  form,  the  bottom  of  which  was  formed  by  the 
pancreas,  the  coats  of  the  stomach  having  been  in  this  part  entirely  destroyed. 
A dense  cellular  tissue  united  the  edges  of  the  ulcer  to  the  pancreas,  and  thus,  by 
a wondrous  resource  of  nature,  prevented  effusion  into  the  abdominal  cavity. 
Around  this  ulcer  the  coats  of  the  stomach,  which  were  considerably  thickened, 
had  degenerated  into  a white  lardaceous  tissue.  The  bottom  of  the  ulcer  itself 
presented  a blackish  layer,  reduced  to  putrilage.  Beneath  this  layer,  which  was 
from  four  to  five  lines  in  thickness,  the  tissue  of  the  pancreas  had  retained  its 
natural  appearance. 


SECTION  II. 

ALTERATIONS  OE  THE  TISSUES  SUBJACENT  TO  THE  MUCOUS  MEMBRANE. 

In  the  preceding  paragraph,  I endeavoured  particularly  to  describe  the  numer- 
ous and  varied  alterations  which  the  gastric  mucous  membrane  may  undergo 
when  affected  with  chronic  inflammation.  In  this  second  article  I shall  treat  of 
the  lesions  of  the  other  tissues  which  enter  into  the  composition  of  the  parietes 
of  the  stomach. 

Situate  beneath  the  mucous  membrane,  and  still  dependent  on  it,  the  follicles, 
scattered  over  the  internal  surface  of  the  stomach,  present  certain  alterations, 
which  act  an  important  part  in  the  diseases  of  the  stomach.  These  alterations 
principally  regard,  first  their  size ; secondly,  the  structure  of  the  parietes;  thirdly, 
the  nature  of  the  ordinary  secretion  of  these  follicles. 

There  are  stomachs  on  the  inner  surface  of  which  the  most  attentive  examina- 
tion can  with  difficulty  discover  some  cryptae,  which  are  scarcely  apparent;  and 
this  nearly  complete  absence  of  follicles  may  be  found,  as  well  in  a stomach 
apparently  healthy,  as  in  a stomach  in  different  degrees  of  inflammation  of  an 
acute  or  chronic  form.  On  the  internal  surface  of  other  stomachs  the  follicles 
are  much  more  visible;  being  really  hypertrophied,  they  present  themselves  as 
rounded  granulations,  both  separate,  and  aggregated  in  different  points  of  the 
stomach.  It  is  not  probable  that  in  such  cases  the  follicles  observed  are  of  new 
formation  ; but  having  been  too  small  in  their  normal  state  to  be  perceptible,  they 
became  apparent  according  as  the  inflammation,  by  rendering  them  the  seat  of 
a more  active  nutrition,  has  increased  their  size.  This  unusual  development  of 
the  follicles  in  the  stomach  may  be  either  partial  or  general ; when  partial,  it  is 
observed  principally  around  two  points;  first,  around  and  a little  beneath  the 
cardiac  orifice  ; secondly,  towards  the  pyloric  extremity  of  the  stomach,  to  the 
extent  of  some  fingers’  breadth  beyond  the  point  of  separation  of  this  organ  and 
the  duodenum.  The  mucous  crypts  are  sometimes  found  so  much  enlarged  and 
so  agglomerated  in  this  situation,  that  the  internal  surface  of  the  stomach  then 
resembles  the  structure  of  the  duodenum,  particularly  in  the  first  flexure  of  this 
organ,  where  the  mucous  cryptae  are  larger,  more  numerous,  and  closer  to  each 
other  than  in  any  other  point  of  the  digestive  tube,  except,  however,  where 
Peyer’s  glands  exist;  these  latter,  in  their  normal  slate,  are  much  less  volumi- 
nous than  the  cryptae  of  the  duodenum. 


DISEASES  OF  THE  AB DOMEX, 


241 


When  the  development  of  the  gastric  follicles  is  general,  two  varieties  of  ap- 
pearance are  presented  on  the  internal  surface  of  the  stomach.  Sometimes  a 
great  number  of  granulations  are  scattered  over  its  entire  surface,  of  various  sizes, 
white,  grey,  red,  or  brownish,  in  the  centre  of  which  one  may  often  discover  an 
orifice,  frequently  surrounded  by  a red  or  black  vascular  circle.  Sometimes, 
in  consequence  of  a still  greater  development  of  the  follicles,  the  mucous  mem- 
brane presents  a mamillated  appearance  over  a greater  or  less  portion  of  its  sur- 
face. At  first  view,  one  might  suppose  that  this  mamillated  appearance  de- 
pends on  the  unequal  hypertrophy  of  the  mucous  membrane  in  its  different 
parts  ; this  may  be  true  in  some  cases ; but  attentive  examination  has  more 
than  once  satisfied  me,  that  the  mamillary  appearance  of  the  gastric  mucous 
membrane  may  also  be  owing  to  the  simultaneous  increase  of  nutrition  in  a 
great  number  of  the  follicles  ; it  is  these  latter,  which,  being  hypertrophied, 
constitute  the  mamillae  ; and  the  depressions,  or  furrows,  which  are  between 
them,  appear  to  be  merely  portions  of  mucous  membrane  not  raised  by  the  fol- 
licles. When  the  internal  surface  of  the  stomach  presents  this  mamillated  ap- 
pearance, there  usually  exists  at  the  same  time  a grey  or  brown  colour  of  the 
mucous  membrane,  and  during  life  the  different  appearances  which  characterise 
chronic  gastritis  are  observed.  More  than  once  I found  no  other  lesion  in  per- 
sons who  had  presented  all  the  rational  signs  of  what  is  called  a cancerous 
affection  of  the  stomach,  such  as  lancinating  pain  in  the  epigastrium,  whether 
continued  or  not ; pale  yellow  tint  of  countenance,  marasmus,  vomiting  of  food, 
and  of  black  matters,  etc. 

Such  are  the  principal  alterations  which  the  mucous  follicles  of  the  stomach 
present  in  the  human  subject;  but  in  the  horse  I have  frequently  found  in  these 
same  follicles  other  lesions  which  appear  to  me  particularly  deserving  of  atten- 
tion, from  the  inferences  which  may  be  deduced  from  them  with  respect  to  the 
nature  of  some  of  the  disorganizations  and  changes  of  several  of  our  tissues. 

It  is  not  uncommon  to  see  rounded  tumours  on  the  inner  surface  of  the  horse’s 
stomach,  the  size  of  which  varies  from  that  of  a cherry  or  a walnut  to  that  of  a 
large  orange.  The  mucous  membrane  passes^  over  them,  and  in  the  centre  of 
each  is  an  orifice,  through  which  a probe,  being  introduced,  readily  passes  into 
the  interior  of  the  tumour,  which,  far  from  being  solid  in  its  structure,  forms  on 
the  contrary  a mere  pouch,  filled  with  a liquid,  which  varies  in  its  nature  and 
consistence.  Sometimes  this  liquid  resembles  mucus,  sometimes  it  presents  a 
purulent  appearance  ; at  other  times  it  has  more  consistence,  is  of  a grumous 
character  and  friable,  of  a dull  white  or  light  yellow  colour  ; whilst  at  other 
times  it  resembles  honey,  or  that  which  escapes  from  melicerous  tumours,  de- 
veloped beneath  the  skin  ; in  more  than  one  instance  the  matter  accumulated 
within  these  tumours  resembled  the  sebaceous,  fatty  matter,  found  in  certain 
cutaneous  pimples.  The  anatomical  composition  of  the  parietes  of  these  tumours 
was  not  less  variable  than  the  nature  of  the  liquid  which  they  contained.  In 
some  these  parietes  were  very  thin,  and  were  formed  of  prolongations  of  the 
mucous  membrane,  covered  externally  by  a more  or  less  dense  layer  of  cellular 
tissue.  In  other  tumours  this  cellular  layer  gradually  assumed  a fibrous  aspect, 
and  sometimes  was  found  to  be  changed  into  real  cartilage. 

I have  sometimes  seen  the  fibrous  or  cartilaginous  parietes  of  these  tumours 
divided  into  very  many  cells,  which  contained  a number  of  entozoa,  having  all 
the  characters  of  the  nematodes  of  Rudolphi,  of  a beautiful  white  colour,  very 
thin  at  their  two  extremities,  from  one  to  two  lines  in  length,  of  the  thickness 
of  a hair,  moving  with  great  agility  in  the  cells  in  which  they  were  accumulated, 
being  found  also  inside  the  principal  pouch,  escaping  through  the  central  orifice 
of  the  latter,  and  spreading  over  the  internal  surface  of  the  stomach.  These 
worms  were  not  the  product  of  putrefaction,  for  they  were  found  in  horses  which 
were  opened  immediately  after  being  slaughtered, 

21 


242 


ANDRAL’S  MEDICAL  CLINIC. 


What  is  the  nature  of  these  tumours  ? If  for  the  purpose  of  discovering  it  we 
commence  by  opening  the  largest  of  them,  we  are  left  in  uncertainty  with  re- 
spect to  their  origin  and  their  mode  of  formation,  and  we  are  induced  to  class 
them  among  those  cysts  which  may  be  developed  within  the  animal  tissues, 
and  particularly  within  the  cellular  structure  which  surrounds  and  separates  these 
different  tissues.  Stili,  on  examining  even  the  most  complicated  case,  one  cir- 
cumstance almost  invariably  strikes  the  observer,  and  that  is,  the  existence  of 
an  orifice  in  the  centre  of  these  tumours  ; the  regularity  of  this  orifice,  its  uni- 
form position,  its  diameter,  which  is  always  the  same,  the  appearance  of  its 
edges,  are  incompatible  with  the  idea  of  a solution  of  continuity,  and  already 
induce  us  to  suspect  that  this  is  a natural  opening,  and  that  it  is  probably  the 
dilated  orifice  of  an  enlarged  follicle.  However,  this  is  but  a mere  presumption  ; 
and  if  we  study  smaller  tumours  with  more  simple  parietes,  this  presumption 
becomes  a certainty  : we  see  the  follicle  become  enlarged  by  insensible  degrees, 
its  parieties  become  hypertrophied,  its  cavity  dilated,  new  tissues  developed 
around  it,  and  the  mucus,  which  it  secretes  in  the  normal  state,  become  regu- 
larly changed  into  purulent,  tuberculous,  sebaceous,  melicerous,  or  cretaceous 
matter,  and  replaced  at  length  by  a fluid,  within  which  living  beings,  entozoa, 
are  developed.  When  once  these  successive  changes  are  perceived  and  appre- 
ciated, the  nature  of  the  largest  of  these  tumours  is  no  more  difficult  to  be  ascer- 
tained than  that  of  the  smallest  and  most  simple.  Some  of  these  tumours  pre- 
sent no  central  orifice  ; but  as  every  other  part  is  the  same,  we  must  only  infer 
that  this  orifice  has  become  obliterated  in  the  same  manner  as  we  frequently  see 
the  orifice  of  the  cutaneous  follicles  disappear,  which,  being  enlarged,  become 
dark  pimples  ( tannes ).  Thus,  and  this  is  the  general  conclusion  which  I shall 
deduce  from  the  preceding  facts,  a tissue  or  organ  when  it  has  once  deviated 
from  its  normal  mode  of  nutrition,  may  undergo  the  most  varied,  the  mostunex- 
pected  changes,  whether  in  its  form,  or  in  its  texture  ; and  in  this  series  of 
changes  it  may  become  so  unlike  itself,  that  it  would  not  be  recognised  if  we  did 
not  study  in  their  regular  order  the  numerous  changes  which  it  has  undergone. 
By  proceeding  in  this  way  we  may  often  prove  that  several  accidental  produc- 
tions, which  are  considered  as  tissues  of  an  entirely  different  nature,  and  are 
produced  entirely  within  the  tissues  of  the  normal  state,  are  but  these  latter  tis- 
sues modified.  I have  elsewhere  endeavoured  to  prove  that  this  was  the  case, 
for  instance,  with  the  pulmonary  granulations  ;*  and  in  the  continuation  of  this 
work  I shall  endeavour  to  comprise  under  this  head  the  formation  of  scirrhous 
degeneration  of  the  stomach. 

The  liquids  secreted  by  the  healthy  stomach  may  be  more  or  less  altered  with 
respect  to  their  quantity  and  qualities  in  cases  of  chronic  gastritis.  An  individual 
who  entered  the  Charite  with  all  the  symptoms  of  this  disease,  vomited  every 
day,  for  a long  time,  nearly  four  pints  of  a whitish  glairy  mucus,  resembling  the 
white  of  egg  before  it  is  boiled.  This  mucus  was  vomited  several  times  in  the 
twenty-four  hours  ; what  was  most  remarkable  in  the  case  is,  that  the  little  food 
taken  by  the  patient  was  never  vomited.  On  opening  the  body,  no  other  lesion 
was  found  in  the  stomach  except  thickening  of  the  mucous  membrane,  with  a 
brown  colouring  of  its  tissue  and  very  marked  enlargement  of  the  follicles. 

Among  the  matters  found  after  death  in  the  stomach  in  chronic  inflammation, 
and  which  are  sometimes  vomited  during  life  in  prodigious  quantity,  we  must 
not  forget  that  black  matter,  which  has  for  so  long  a time  engaged  the  attention 
of  pathologists,  and  which  has  been  compared  to  a solution  of  chocolate,  or  to 
coffee-grounds.  Two  questions  may  be  started  here  : first,  what  is  the  nature 
of  this  matter  ? second,  is  its  secretion  connected  with  any  special  lesion  of  the 
stomach  ? 


* Pathological  Anatomy, 


DISEASES  OF  THE  ABDOMEN. 


243 


I sent  to  M.  Lassaigne  a certain  quantity  of  black  matter  vomited  by  a woman, 
who  for  more  than  a month  had  been  throwing  up  a pint  of  it  every  day.  It 
contained  water,  albumen,  a free  acid  of  an  organic  nature,  and  further,  it  was 
rendered  turbid  and  blackish  by  holding  in  suspension  a deep  brown  colouring 
matter,  insoluble  in  water,  but  soluble  in  sulphuric  acid,  and  presenting,  when 
thus  dissolved,  a beautiful  blood-red  colour,  similar  to  that  presented  by  the 
colouring  matter  of  the  blood  in  the  same  acid.  When  submitted  to  calcina- 
tion, it  burned  without  swelling,  and  left  a slight  residue  of  a brick  colour,  con- 
sisting of  peroxide  of  iron,  and  traces  of  phosphate  of  lime,  just  as  it  is  furnished 
by  the  colouring  matter  of  the  blood. 

From  this  analysis  it  follows  that  the  black  colour  of  the  matters  vomited  in 
certain  affections  of  the  stomach  is  owing  to  the  presence  of  an  organic  element 
closely  resembling  the  colouring  matter  of  the  blood.  Such  is  the  conclusion 
to  which  M.  Breschet  also  came,  when  after  having  proved  in  his  beautiful 
work  on  melanosis,  that  this  accidental  production  is  principally  formed  of  a 
colouring  matter  very  similar  to  that  of  the  blood,  induction  led  him  to  class 
the  matter  of  black  vomit  under  the  head  of  melanosis.  In  another  work*  I 
tried  to  confirm  this  opinion  by  new  proofs.  In  a stomach  which  I recently 
examined,  I found  black  colouring  matter  under  two  forms.  First  it  existed 
free  in  the  cavity  of  the  stomach,  on  the  inner  surface  of  which  it  had  been 
secreted,  and  further,  in  several  places,  it  was  combined  with  the  gasftic  mu- 
cous membrane,  and  gave  it  a beautiful  black  colour,  in  the  same  manner  as 
it  colours  certain  portions  of  mucous  membranes  in  several  animals  in  the 
normal  state. 

Thus  then,  with  respect  to  its  chemical  composition  as  well  as  to  its  colour, 
the  matter  of  black  vomit  should  be  considered  as  similar  to  the  matter  of  me- 
lanosis ; like  the  latter,  it  is  formed  principally  of  a colouring  matter,  which 
resembles  very  strongly  that  of  the  blood.  It  must  be  admitted  that  in  the  act 
which  separates  it  from  the  blood,  it  may  be  more  or  less  modified ; the  result 
of  which  will  be,  that  under  some  circumstances  it  will  be  completely  identical 
with  the  matter  which  gives  its  colour  to  the  blood,  whilst  under  other  circum- 
stances it  will  differ  more  or  less  from  it.f  This  same  thing  happens  with 
respect  to  several  other  products,  of  the  healthy  or  morbid  state,  which  come 
from  the  blood.  Thus  the  serum  separated  from  the  blood  on  the  surface  of 
serous  membranes  is  no  longer  the  same  as  that  which  is  found  in  the  blood 
with  respect  to  the  proportion  of  water,  albumen,  and  the  salts  it  contains. 
The  same  may  be  said  of  the  fibrin,  etc. 

We  shall  here  give  the  history  of  a case  in  which  black  matter  was  found 
scattered  over  the  internal  surface  of  the  stomach  in  the  form  of  black  spots,  at 
the  same  time  that  it  existed  free,  and  in  a liquid  form  in  the  cavity  of  the  organ. 

Case  3. — Melanosis  of  the  stomach — No  other  gastric  symptoms  but  total  loss  of  appetite — 
Dropsy  without  any  appreciable  lesion  to  account  for  it. 

A woman,  about  fifty  years  of  age,  died  in  the  Charite  during  the  month  of 
February.  At  the  time  of  her  entering  the  hospital  she  had  general  serous  in- 
filtration of  the  subcutaneous  cellular  tissue  and  ascites.  To  no  purpose  did 

* Pathological  Anatomy. 

f It  is  possible  that  further  researches  may  prove  that  the  black  colouring  matter  which 
constitutes  melanic  productions  differs  altogether  in  certain  cases,  with  respect  to  its  chemical 
composition,  from  the  colouring  matter  of  the  blood,  and  that  it  is  then  a secretion  of  a new 
formation,  just  as  the  numerous  colouring  matters,  blue,  green,  etc.,  which  so  richly  tint  the 
skins  and  coverings  of  several  animals.  Some  physiological  data  would  incline  me  for  in- 
stance to  think  that  the  black  colouring  matter  of  the  lungs,  which  abounds  so  much  in  old 
persons,  is  principally  formed  of  carbon. 


244 


ANDRAL’S  MEDICAL  CLINIC. 


we  endeavour  to  find  out  the  cause  of  this  state;  the  pulsation  of  the  heart 
seemed  to  be  natural ; there  was  no  sign  of  any  disease  of  the  liver  or  of  any 
other  viscus.  The  previous  history  of  the  case  did  not  throw  any  light  on  it; 
she  stated  that  her  dropsy  had  set  in  gradually,  commencing  at  the  extremities, 
and  extending  to  the  abdomen  ; she  had  never  felt  any  pain  in  the  latter  part, 
nor  any  difficulty  of  breathing  till  the  ascites  had  become  considerable.  For 
the  six  weeks  which  elapsed  between  her  admission  and  death,  the  dropsy  did 
not  diminish  ; the  general  debility  constantly  increased  ; some  diarrhoea  occurred 
from  time  to  time,  and  there  was  complete  loss  of  appetite ; no  pain  in  the 
epigastrium,  no  vomiting,  the  appearance  of  the  tongue  natural.  The  patient 
went  on  sinking  gradually,  and  died  without  presenting  any  new  symptoms. 

On  opening  the  body  no  lesion  was  found  in  the  heart  or  its  appendages. 
The  lungs  were  engorged  posteriorly,  but  healthy  in  other  respects.  The 
thoracic  duct  contained,  as  usual,  a little  colourless,  limpid  serum.  A similar 
liquid  was  effused  in  great  quantity  into  the  peritoneum,  which  presented  not 
the  slightest  trace  of  inflammation.  Liver  to  all  appearance  healthy.  But  the 
stomach  presented  a species  of  change,  which  could  scarcely  have  been  antici- 
pated. On  making  an  incision  into  it  along  its  great  curvature,  there  escaped 
a fluid  black  as  ink,  and  which,  when  brought  in  contact  with  linen  and  white 
paper,  gave  them  a tint  similar  to  that  which  would  have  been  produced  by 
applying  the  choroid  membrane  to  these  substances.  The  quantity  of  this 
liquid  contained  in  the  stomach  might  be. estimated  at  about  three  ordinary 
glassfuls.  The  inner  surface  of  the  stomach  having  been  washed  and  well 
cleaned,  we  found  it  dotted  with  a great  number  of  spots  of  a deep  black  colour, 
all  accurately  circular  or  oval.  Three  or  four  of  these  spots  were  a little  broader 
than  a two-franc  piece  : eight  or  ten  of  them  were  the  size  of  a franc  piece ; the 
others,  much  more  numerous,  were  from  the  size  of  a ten  or  five  sous  piece  to 
that  of  a grain  of  millet;  in  other  parts  they  presented  themselves  merely  as 
very  small  black  points.  Around  the  two  larger  spots  and  a few  of  the  others 
the  mucous  membrane  presented  a livid  red  colour,  which,  being  considerably 
marked  for  the  space  of  some  lines  around  the  black  spot,  became  gradually 
fainter  according  as  it  receded  ; around  the  other  spots,  in  the  intervals  between, 
and  in  every  other  part,  the  inner  surface  of  the  stomach  was  pale,  and  the 
mucous  membrane  presented  no  appreciable  alteration  with  respect  to  its  con- 
sistence and  thickness.  It  was  only  in  the  mucous  membrane  that  the  black 
colour  existed,  but  it  presented  it  equally  strong  on  its  two  surfaces  ; where  it 
was  thus  coloured,  it  was  a little  thicker  and  more  resisting  than  elsewhere.  In 
some  points  the  cellular  tissue  subjacent  to  the  black  points  was  reddish.  We 
observed  nothing  remarkable  in  the  rest  of  the  digestive  tube. 

When  we  perceived  these  black  spots  like  ebony  scattered  over  life  internal 
surface  of  the  stomach,  we  were  struck  by  their  strong  resemblance  to  red 
gangrenous  patches,  and  particularly  to  the  eschars  occasioned  by  concentrated 
sulphuric  acid  when  taken  into  the  stomach.  Still  no  gangrenous  odour  was 
exhaled  from  the  stomach  ; the  manner  of  the  patient’s  death  repelled  all  idea 
of  poisoning  by  a corrosive  substance  ; there  was  no  symptom  of  any  acute 
affection  of  the  stomach  ; on  the  other  hand  a resemblance  might  be  observed 
between  the  nature  of  the  black  spots  of  the  mucous  membrane,  and  that  of  the 
liquid  of  the  same  colour  contained  in  the  stomach.  Hence  we  renounced  all 
idea  of  a gangrenous  affection,  an  idea  which  accorded  neither  with  the  nature 
of  the  symptoms,  nor  with  that  of  the  lesions  when  more  attentively  examined. 
In  this  case  we  saw  nothing  but  melanosis  of  the  stomach,  in  other  words,  a 
secretion  of  black  colouring  matter,  which,  on  the  one  hand,  had  been  deposited 
in  the  tissue  itself  of  the  mucous  membrane,  whence  the  accidental  black  colour 
of  this  membrane,  similar  to  that  which  exists  naturally  in  animals  in  certain 
portions  of  their  mucous  membranes,  and  which,  on  the  other  hand,  had  been 


DISEASES  OF  THE  ABDOMEN.  245 

exhaled  on  the  free  surface  of  the  mucous  membrane,  whence  came  the  black 
fluid  in  the  interior  of  the  stomach. 

I thought  it  useful  to  publish  this  fact : first,  because  but  very  few  examples 
of  similar  deposition  of  black  pigment  in  the  form  of  circumscribed  spots  in  the 
tissue  of  the  gastric  mucous  membrane  have  been  as  yet  recorded  ; secondly, 
because  this  fact  may  not  be  devoid  of  importance  in  reference  to  forensic 
medicine,  as  presenting  lesions  which  in  some  respects  resemble  those  which 
may  be  occasioned  by  sulphuric  acid  • thirdly,  because  this  fact  proves  that  a 
matter  similar  to  that  which  constitutes  black  vomiting  in  certain  cancers  of  the 
stomach,  may  be  exhaled  in  this  organ  without  any  cancerous  affection,  or  even 
without  gastritis ; for  here  in  the  interval  between  the  black  spots,  the  mucous 
membrane  was  very  healthy,  and  there  is  nothing  to  prove  that  these  black 
patches  were  the  result  of  an  inflammatory  process.  It  is  probable  that  the 
black  pigment  effused  into  the  stomach  formed  there  during  life  in  only  a very 
small  quantity,  so  as  to  be  able  to  pass  entirely  into  the  duodenum;  for  if  it 
were  more  abundant  it  must  have  been  discharged  by  vomiting.  Probably  also 
its  exhalation  did  not  commence  until  a little  time  before  death.  We  should  not 
forget  how  little  marked  the  gastric  symptoms  were.  Loss  of  appetite  was  the 
only  sign  of  any  gastric  disturbance.  Another  remarkable  circumstance  in  this 
case  is  the  existence  of  dropsy  (anasarca  and  ascites)  without  any  appreciable 
lesion,  whether  mechanical  or  inflammatory,  which  can  account  for  it.  Here  it 
is  not  in  our  power  to  ascend  to  the  cause  which  produced  this  dropsy  ; for  to 
say  that  it  depended  on  over-activity  of  the  exhalants  or  atony  of  the  absorbents, 
or  on  a want  of  equilibrium  between  these  two  orders  of  vessels,  is  mere  hypo- 
thesis. All  we  see  is  an  increase  of  quantity  in  the  liquid  which  filled  the 
areolae  of  the  cellular  tissue,  and  the  serous  membrane  of  the  abdomen.  Thus, 
then,  notwithstanding  the  great  light  which  modern  researches  have  thrown  on 
the  etiology  of  dropsy,  experience  obliges  us  to  admit  that  there  are  still  some 
cases  in  which  neither  the  study  of  the  symptoms  nor  pathological  anatomy 
can  as  yet  reveal  the  cause. 

I already  tried,  in  a preceding  part  of  this  work,  to  show,  how,  consecutively 
to  inflammation  of  the  mucous  membrane,  and  whether  this  inflammation  still 
continues  or  has  disappeared,  the  tissues  subjacent  to  it  may  undergo  different 
species  of  alteration,  which  we  shall  now  describe. 

In  the  number  of  those  tissues  or  anatomical  elements,  besides  the  mucous 
membrane,  which  enter  into  the  structure  of  the  parietes  of  the  stomach,  we 
must  place  in  the  first  rank,  with  respect  to  the  frequency  and  importance  of 
their  alterations,  the  two  cellular  layers  placed,  one  between  the  mucous  and 
muscular  membrane,  the  other  between  the  latter  and  the  peritoneum,  which 
are  connected  together  by  cellular  prolongations  extended  between  the  fasciculi 
of  the  muscular  tunic.  When  they  are  attacked  with  inflammation,  and  their 
normal  nutrition  has  become  deranged,  these  different  portions  of  the  cellular 
tissue  may  undergo  changes  of  the  most  varied  character  with  respect  to  their 
form  and  texture  ; thence  the  same  thing  happens  with  respect  to  their  morbid 
states  as  we  have  already  seen  happen  in  certain  diseases  of  the  follicles,  namely, 
that  for  want  of  tracing  their  successive  development,  their  origin  and  nature 
have  been  more  or  less  mistaken. 

The  submucous  cellular  tissue  is  seldom  altered  in  cases  of  acute  inflamma- 
tion, when  the  mucous  membrane  is  most  seriously  affected  ; sometimes,  how- 
ever, it  then  becomes  injected  or  softened  ; it  may  also  remain  intact  in  several 
cases  of  chronic  gastritis,  whatever  be  the  different  degrees  of  intensity  and 
duration  of  the  latter.  But  at  other  times  this  cellular  tissue  is  also  attacked 
by  inflammation,  either  singly  and  by  itself,  or  simultaneously  with  the  other 
portions  of  the  cellular  tissue  which  enter  into  the  structure  of  the  parietes  of 
the  stomach.  There  are  cases  in  which  it  becomes  attenuated  like  the  mucous 
21* 


246 


ANDRAL’S  MEDICAL  CLINIC. 


membrane,  and  like  it  also,  it  ultimately  disappears  ; at  other  times  it  becomes 
softened,  and  changed  into  a liquid  pulp ; and  then  this  submucous  cellular 
layer,  which  on  the  one  hand  makes  up  for  the  want  of  strength  of  the  mucous 
membrane,  and  on  the  other  hand  is  continued  into  the  interstices  between  the 
fasciculi  of  the  muscular  coat,  then  altogether  ceases  to  exist  under  the  form  of 
a solid,  resisting  membrane  ; in  such  a slate  of  things  the  parietes  of  the  stomach 
lose  a considerable  portion  of  the  resisting  power  which  they  oppose  to  the 
different  causes  which  tend  to  produce  in  them  a solution  of  continuity.  We 
then  see  the  stomach  easily  ruptured  after  a great  quantity  of  drink  has  been 
taken  into  its  cavity,  after  more  or  less  powerful  contraction  of  the  abdominal 
muscles,  or  in  consequence  of  internal  violence  applied  to  the  epigastrium. 

Increase  in  the  thickness  and  consistence  of  the  cellular  tissue  is  observed  in 
many  cases  wherein  the  different  tissues  with  which  it  is  connected  are  in  a 
state  of  chronic  inflammation.  This  often  happens  with  respect  to  the  cellular 
tissue  which  connects,  and  at  the  same  time  separates,  the  different  coats  of  the 
stomach.  From  the  different  degrees  of  thickening  and  induration  of  this  tissue 
comes  that  species  of  alteration  of  texture  which  has  been  generally  described 
by  writers  under  the  name  of  scirrhus  of  the  stomach.  According  as  the  gastric 
cellular  tissue  becomes  thickened  and  indurated,  it  deviates  more  and  more  from 
its  normal  appearance,  and  undergoes  remarkable  changes  ; but  amidst  these 
successive  changes  we  may  trace  with  the  scalpel  the  different  stages  through 
which  it  passes  in  order  to  reach  them.  The  most  common  change  which  it 
undergoes  is  that  in  which  it  presents  itself  under  the  form  of  a greyish,  bluish, 
or  dull  white  tissue,  of  a homogeneous  appearance,  without  any  traces  of  ves- 
sels, hard  and  friable  under  the  scalpel.  This  is  scirrhus  par  excellence . 
There  is  no  objection  to  the  use  of  this  term,  provided  we  rightly  understand 
its  import,  and  do  not  take  it  to  signify  a new  tissue  formed  in  the  system, just 
as  an  entozoaire  is,  whilst  it  is  in  reality  nothing  but  the  change  of  a tissue 
from  its  normal  state.  In  fact,  where  is  scirrhus  found  ? Never  in  any  other 
tissues  but  in  the  cellular  tissue  interposed  between  them.  At  the  same  time 
that  the  cellular  fibre  surrounding  them  is  indurated  and  becomes  scirrhous, 
those  tissues  may  be  changed  in  different  ways  ; they  may  ultimately  be  de- 
stroyed and  disappear,  but  they  do  not  really  become  scirrhus.  This  is  very 
evident  in  the  case  of  mucous  membranes.  On  the  other  hand,  observe  indu- 
rated cellular  tissue  in  different  parts  of  the  system,  and  you  will  be  struck 
with  a singular  contradiction  of  authors,  who  consider  a tissue  to  be  scirrhus 
which  is  absolutely  similar  to  another  to  which  they  invariably  give  the  name 
of  simple  induration.  Thus  in  a great  number  of  chronic  diarrhoeas,  the  sub- 
mucous cellular  tissue  of  the  large  intestine  becomes  much  more  developed  than 
natural ; it  is  changed  into  a hard,  whitish,  and  homogeneous  tissue.  If  its 
increase  of  thickness  is  general  and  still  inconsiderable,  the  only  result  is  a 
certain  rigidity  in  all  the  parietes  of  the  great  intestine,  it  is  not  yet  scirrhus  ; 
but  if  the  appearance  of  the  tissue  being  in  other  respects  absolutely  the  same, 
the  increase  in  thickness  is  partial,  and  considerable  enough  to  occasion  a tu- 
mour, that  which  was  a little  while  ago  simple  hardening  of  the  cellular  tissue, 
now  becomes  a new  tissue,  and  is  called  scirrhus.  Neither  is  this  name  given 
to  the  hardening  so  often  observed  in  the  cellular  tissue  either  at  the  bottom  of 
ulcers  of  the  mucous  membranes,  or  around  old  cutaneous  ulcers,  or  along  the 
course  of  a fistula,  or  around  several  white  tumours  of  the  joints,  or  in  the 
vicinity  of  a caries,  or  necrosis.  Yet,  in  these  different  cases  the  alteration 
called  hardening  of  the  cellular  tissue  presents  an  appearance  identical  in  every 
respect  with  the  alteration  which  in  the  stomach  is  called  by  the  name  of 
scirrhus. 

Sometimes  the  submucous  cellular  tissue  of  the  stomach  presents  not  only  the 
state  of  simple  induration  now  in  question  (the  scirrhus  of  authors);  it  is  not  only 


DISEASES  OF  THE  ABDOMEN. 


2 47 


hypertrophied,* but  it  undergoes  a real  change;  it  assumes  the  characters  of  the 
cartilaginous  tissue,  and  more  particularly  of  that  imperfect  cartilaginous  tissue, 
still  soft  and  inelastic,  which  exists  at  first  in  the  embryo.  However,  a real 
transformation  into  cartilage  is  much  more  uncommon  in  the  sub-mucous  than  in 
the  sub-serous  cellular  tissue. 

If  instead  of  being  greyish  or  bluish,  as  it  were  semi-transparent,  the  indurated 
cellular  tissue  of  the  stomach  is  of  a dull  white  colour,  and  opaque  ; if  instead  of 
being  devoid  of  vessels,  it  is  traversed  by  vascular  ramifications,  more  or  less 
numerous,  it  is  then  no  longer  scirrhus  ; it  is  cerebriform  or  encephaloid  tissue, 
said  to  be  developed  in  the  parietes  of  the  stomach.  For  a long  time  I admitted 
this  distinction  ; but  I own  that  more  extended  researches  have  proved  to  me  that 
it  was  all  arbitrary.  In  the  majority  of  cases  we  see  the  two  tissues  called  scirrhus 
and  encephaloid,  confounded  by  insensible  shades;  and  ultimately  the  latter  ap- 
pears, like  the  former,  to  be  merely  a form  of  induration  which  the  sub-mucous 
cellular  tissue  of  the  stomach  has  undergone.  It  is  obvious  that  in  these  different 
degrees  of  aberration  of  nutrition,  this  cellular  tissue  has  many  degrees  of  colour. 
And  with  respect  to  the  presence  or  absence  of  vessels,  do  wre  not  see  that  that 
is  a circumstance  purely  accidental  ? If  in  the  normal  state  the  sub-mucous  cel- 
lular tissue  is  traversed  by  vessels,  it  follows  that  these  vessels  must  still  exist 
in  this  same  cellular  tissue  hypertrophied;  but  they  will  be  more  or  less  apparent 
according  to  the  degree  of  sanguineous  congestion  which  may  exist  in  this  tissue 
at  the  time  of  examination. 

The  presence  or  absence  of  vessels  in  the  indurated  cellular  tissue  it  is  then  of 
some  importance  to  remark,  not  for  the  purpose  of  establishing  from  it  two  kinds 
of  morbid  tissues,  but  in  order  that  we  may  thus  admit  the  greater  or  less  activity 
of  sanguineous  congestion,  and  of  inflammation  in  this  same  cellular  tissue. 
Thence  arise  different  symptoms  which  will  not  result  from  the  presence  of 
morbid  tissues  really  different,  but  only  from  different  degrees  of  inflammation 
of  one  and  the  same  tissue. 

At  the  same  time  that  the  nutrition  of  the  gastric  cellular  tissue  is  altered, 
secretions  of  various  kinds  may,  and  in  fact  do,  often  go  on  there.  Oftentimes  in 
the  midst  of  the  indurated  portions  of  this  tissue,  we  find  a kind  of  areolae,  or 
cells,  containing  a semi-liquid  matter,  like  jelly,  or  honey  ; it  is  said  that  this  is 
softened  scirrhus  ; but  that  is  assertion  without  proof ; and  if  this  matter  is  alto- 
gether similar  to  that  which  is  found  in  a great  many  cysts  with  serous  parietes, 
if  it  is  found  in  certain  compound  tumours  of  the  ovary,  and  the  thyroid  gland, 
where  it  is  contained  in  distant  cells,  and  where  nothing  around  it  resembles 
scirrhus  ; if  it  be  observed  within  cartilaginous  masses,  where  nothing  else  is 
seen  except  a gluelike  matter  arranged  in  cavities,  whose  parietes  consist  solely 
of  cartilage  ; if,  as  I once  saw  in  the  pleura,  a similar  matter  may  form  on  a 
serous  membrane,  which  evidently  secreted  it  instead  of  serum  ; if,  in  a word, 
in  these  different  cases,  this  so  called  scirrhus  in  the  state  of  softening  presents 
itself  as  a simple  product  of  secretion,  independent  altogether  of  any  previous 
scirrhus  state,  strict  analogy  will  induce  us  to  conclude  that  the  matter  resem- 
bling jelly,  or  honey,  often  found  in  the  midst  of  the  indurated  cellular  tissue  of 
the  stomach,  is  not  this  same  tissue  softened  ; but  that  in  this,  as  in  other  cases 
already  cited,  it  is  a new  product  deposited  there  by  secretion. 

At  other  times,  within  this  same  indurated  cellular  tissue,  another  species  of 
secretion  takes  place  ; namely,  a liquid,  opaque  matter,  sometimes  of  a dull  white, 
sometimes  of  a greyish  colour,  oftentimes  tinged  with  blood  ; it  is,  in  a word,  one 

* Since  the  first  edition,  my  opinion  on  the  nature  of  scirrhus  has  been  a little  modified,  and 
it  will  be  seen,  in  my  Pathological  Anatomy,  that  scirrhus  no  longer  appears  to  me  to  consist 
merely  in  a simple  state  of  hypertrophy  of  the  cellular  tissue.  There  is  also  a process  of 
morbid  secretion  in  the  part  where  it  forms. 


248 


ANDRAL’S  MEDICAL  CLINIC. 


of  those  varieties  of  the  morbid  liquid  designated  by  the  generic  term  pus. 
Whatever  may  be  the  shades  of  its  physical  properties,  it  presents  itself  under 
two  appearances  ; sometimes  it  is  really  infiltrated  in  the  midst  of  the  cellular 
tissue,  which  has  become  changed  into  what  is  called  a scirrhous  or  encephaloid 
tumour  ; it  may  be  forced  from  it  by  expression  in  the  form  of  a drop  ; it  some- 
times has  a tendency  to  unite  into  a single  abscess  ( foyer ),  which  increases  in 
size,  and  at  last  occupies  a part  of  the  solid  mass,  within  which  it  was  secreted, 
and  wherein  it  was  first  infiltrated.  Then  the  cellular  tissue  in  the  midst  of  which 
this  secretion  of  pus  takes  place,  almost  always  presents  numerous  vessels, 
which  pass  in  different  directions  through  the  tumour  which  it  forms  ; the  pre- 
sence of  these  vessels,  the  secretion  of  this  purulent  liquid,  prove  the  existence 
of  a more  active  inflammatory  process  in  this  tumour  ; from  henceforward 
another  mode  of  alteration  of  nutrition  comes  on  in  the  cellular  tissue  ; after 
being  hypertrophied  under  the  influence  ofslight  irritation,  more  remarkable  for 
its  duration  than  its  intensity,  it  evinces  a tendency  to  ulcerate;  the  vessels 
which  pass  through  it  are  torn,  and  according  to  the  size  of  these  vessels,  the 
result  is  either  a mere  reddish  colouring  of  the  purulent  matter,  or  profuse  and 
fatal  hemorrhage. 

Thus,  in  all  this,  there  are  three  principal  phenomena  to  be  observed  : 1st,  an 
inflammatory  state  more  severe  than,  and  of  a different  nature  from,  that  which 
had  produced  the  hypertrophy  of  the  cellular  tissue  : 2d,  a purulent  secretion  : 
3d,  a tendency  to  the  destruction  of  the  tumour,  according  as  the  inflammation 
proceeds. 

From  the  preceding  facts  and  considerations,  I think  I may  conclude,  that 
among  the  tumours  developed  beneath  the  gastric  mucous  membrane,  those 
which  are  generally  considered  as  formed  of  what  are  called  scirrhous  and  ence- 
phaloid tissues,  in  the  crude  state,  are  merely  forms  of  hypertrophy  of  the  sub- 
mucous cellular  tissue  ; and  with  respect  to  the  state  of  softening  of  these  same 
tissues,  I think  that  this  name  has  been  very  incorrectly  given  to  new  products, 
which  are  deposited  by  the  process  of  secretion  within  the  previously  inflamed 
cellular  tissue.  Other  morbid  secretions  may  still  go  on  there  : thus  tubercu- 
lous matter  is  often  found  there  in  greater  or  less  masses  ; sometimes,  too,  we 
find,  either  in  single  points  or  in  patches  of  greater  or  less  size,  depositions  of 
colouring  matter  of  various  hues,  more  particularly  of  a yellow  or  black  (mela- 
nosis). 

Hypertrophy  of  the  gastric  cellular  tissue  may  be  limited  to  the  sub-mucous 
membrane  of  Bichat  (the  nervous  coat  of  the  ancients)  : this  is  the  most  common 
case.  It  may  be  continued  in  the  portion  of  the  cellular  tissue,  situate  between 
the  fasciculi  of  the  muscular  coat,  which  occasions  whitish  intersections  between 
these  fasciculi,  to  the  consideration  of  which  I shall  return  presently  : finally, 
the  increased  thickness  and  consistence  may  exist  principally  in  the  sub-perito- 
neal cellular  membrane.  This  latter  case  may  take  place  either  separately  by 
itself,  or  simultaneously  with  induration  of  the  other  great  portions  of  the  gastric 
cellular  tissue. 

Hypertrophy  of  the  gastric  cellular  tissue  may  exist  over  the  entire  stomach, 
the  parietes  of  which  are  then  harder  and  thicker  than  in  the  normal  state,  and 
do  not  collapse  when  an  incision  is  made  into  them.  This,  however,  is  not  the 
most  common  case,  and  in  most  instances  the  hypertrophy  is  partial.  The 
point  of  the  stomach  most  frequently  affected  is  the  pylorus,  either  merely  the 
circumference  of  the  orifice  of  communication  between  the  stomach  and  duode- 
num, or  all  the  pyloric  portion  of  the  stomach.  This  same  hypertrophy  has 
also  been  observed  around  the  cardia,  but  much  more  seldom  ; again,  it  may 
exist  through  the  entire  extent  of  the  substance  of  the  stomach.  When  hyper- 
trophy of  the  sub-mucous  cellular  tissue  exists  towards  the  pylorus,  or  towards 
the  cardia,  it  terminates  abruptly  in  the  very  great  majority  of  cases,  where  the 


DISEASES  OF  THE  ABDOMEN. 


249 


duodenum  and  oesophagus  commence  ; it  may,  however,  pass  the  boundaries 
of  the  stomach,  and  extend  to  one  or  other  of  these  portions  of  the  digestive 
tube  ; in  two  cases  where  there  was  induration  of  the  sub-rnueous  cellular  tissue 
of  the  cardia,  and  surrounding  parts,  I saw  this  same  induration  exist  in  the 
lower  third  of  the  oesophagus,  to  such  a degree  as  to  produce  a visible  narrowing 
of  this  tube. 

The  muscular  tunic  of  the  stomach  remains  intact  in  a very  great  number 
of  cases  of  chronic  gastritis  ; at  other  times  it  is  changed,  and  one  of  the  three 
following  cases  is  then  observed : this  tunic  either  becomes  hypertrophied,  or 
atrophied,  or  it  disappears  completely  over  a greater  or  less  extent  of  the  sto- 
mach. 

Hypertrophy  of  the  musculartunic,  to  which  several  authors,  and  particularly 
Dr.  Louis,  have  paid  considerable  attention,  is  scarcely  ever  observed  separate: 
such,  at  least,  is  the  result  of  my  observation.  We  observe  it  to  be  accompa- 
nied by  a similar  hypertrophy  of  the  cellular  tissue  which  lines  its  two  surfaces, 
and  of  that  which  is  interposed  between  the  fasciculi  which  form  it.  These 
latter,  when  viewed  after  making  a section  of  the  stomach,  appear  formed  of  a 
more  shining,  and  of  a harder  tissue  than  in  the  normal  state  ; if,  as  often  hap- 
pens, the  cellular  tissue  interposed  between  them,  participates  in  the  hyper- 
trophy, the  following  appearance  is  the  result,  which  is  so  much  the  more  de- 
serving of  remark,  as  it  has  given  occasion  to  very  extraordinary  mistakes  : 
white  intersections,  a species  of  septa,  of  a fibrous  appearance  and  consistence, 
extend  from  the  sub-mucous  cellular  tissue  to  the  sub-peritoneal  tissue,  passing 
through  the  muscular  tunic  ; they  divide  the  latter  into  a series  of  lobules, 
which  form  a slight  projection  before  the  white  lines  which  separate  them. 
The  real  nature  of  the  tissue  which  constitutes  these  lobules  may  be  at  first  easily 
mistaken,  in  consequence  of  the  modifications  of  texture  which  the  muscular 
fibre  underwent  in  becoming  hypertrophied,  its  texture  having  now  become 
closer  and  more  condensed.  These  lobules,  and  the  intersections  of  a fibrous 
appearance  which  separate  them,  have  been  generally  described  as  the  type  of 
the  scirrhous  tissue,  and  persons  have  come  to  this  extraordinary  result  of 
describing  in  cancerous  affections  of  the  stomach  a muscular  membrane  as  no 
longer  existing,  and  as  succeeded  by  an  accidental  tissue  of  a new  formation, 
when  this  same  muscular  membrane  was,  on  the  contrary,  hypertrophied. 

But  at  the  same  time  that  the  different  portions  of  the  gastric  cellular  tissue  in- 
crease in  thickness  and  consistence,  there  are  some  cases  where  the  muscular  coat, 
far  from  being  hypertrophied,  becomes  less  and  less  perceptible,  and  undergoes  a 
real  atrophy.  Then  by  careful  dissection  we  find  amidst  masses  of  indurated  cel- 
lular tissue  merely  some  colourless  fibres,  combined  in  small  fasciculi,  separated 
by  large  intervals,  where  no  trace  of  them  is  any  longer  observed.  In  other 
stomachs,  and  always  with  the  same  appearance  of  the  cellular  tissue,  the  mus- 
cular tunic  has  completely  disappeared  to  a greater  or  less  extent,  and  in  its  place 
we  find  only  some  indurated  cellular  tissue,  covered  externally  by  the  perito- 
neum, and  internally  by  a mucous  membrane  more  or  less  changed.  What  do 
we  see  in  these  different  cases?  Increased  nutrition  of  one  tissue,  and  dimi- 
nished nutrition  of  another,  but  nothing  to  warrant  our  admitting  a tissue  of  new 
formation.  It  is,  moreover,  a very  general  fact  in  the  animal  economy,  that  by 
virtue  of  a sort  of  balancing  of  nutrition , the  greater  activity  acquired  by  one 
organ  or  tissue  in  its  vitality,  in  its  functions,  or  in  its  nutrition,  occasions  a 
diminished  activity  in  the  organic  or  animal  functions  of  other  parts.  And  to 
cite  some  facts  analogous  to  that  now  under  consideration,  observe  in  the  limbs 
how  according  as  a tumour  increases  in  the  midst  of  the  cellular  tissue  where 
it  first  commenced,  the  muscles  which  surround  or  pass  through  it  often  lose 
their  colour  and  size,  and  are  reduced  to  a number  of  thin  pale  fibres.  In  a 
case  which  I saw  some  months  ago,  the  fatty  cellular  tissue  behind  the  globe  of 


250 


ANDItAL’S  MEDICAL  CLINIC. 


the  eye  became  so  much  increased,  and  at  the  same  time  indurated,  that  it  filled 
the  entire  cavity  of  the  orbit,  and  even  pushed  the  eyelids  forward  : in  the  midst 
of  the  whitish  and  hard  mass  thus  formed,  the  globe  of  the  eye  was  found  as  it 
were  buried,  and  very  much  diminished  in  size,  and  formed  of  a very  small 
sclerotic,  containing  the  different  membranes  and  humours,  but  only  in  a rudi- 
mental  form  ; the  transparent  cornea  appeared  but  as  a black  point  on  the  ante- 
rior part  of  the  sclerotic.  To  the  latter  membrane  the  six  muscles  of  the  eye 
were  attached  as  usual ; but  they  were  very  small,  colourless,  rudimentary  as 
the  eye  itself  in  which  they  terminated  ; a careful  dissection  was  required,  so 
as  not  to  confound  them  with  the  surrounding  cellular  tissue.  There  then,  as 
in  the  cases  of  chronic  gastritis  already  mentioned,  all  the  elements  which  enter 
into  the  structure  of  the  organ  were  found  ; but  being  modified  in  their  nutri- 
tion, they  no  longer  possessed  their  ordinary  proportions  of  volume.* 

* The  question  has  of  late  been  very  much  discussed,  whether  scirrhus  or  cancer  of  the 
stomach,  such  as  we  have  just  described  it,  should  be  considered  as  one  of  the  products  of 
inflammation  of  this  organ.  It  appears  to  us  reasonable  to  admit  that  an  inflammation  may 
occasionally  produce  a cancer  in  the  stomach,  as  it  occasions  one  in  the  mamma  in  consequence 
of  external  violence.  M.  I^ouillaud  has  published  a case  which  clearly  proves  that  cancer  may 
become  developed  in  the  stomach  after  the  ingestion  of  a certain  quantity  of  nitric  acid  into 
this  viscus.  The  subject  of  the  case  was  a man  thirty-four  years  of  age,  who  had  been  ad- 
dicted to  various  excesses,  and  had  been  suffering  great  domestic  anxiety  for  some  time.  This 
person  attempted  to  poison  himself  with  nitric  acid  ; he  vomited  a considerable  portion  of  the 
poison  immediately  after  swallowing  it,  and  vomiting,  burning  thirst,  and  very  high  fever,  be- 
came the  chief  symptoms  during  the  first  two  or  three  days.  The  throat  also  was  very  painful, 
and  deglutition  very  difficult;  he  was  taken  into  the  Charite  ; leeches  were  applied  to  the 
epigastrium  and  along  the  neck.  It  should  have  been  observed,  that  at  the  time  of  his  ad- 
mission, on  making  him  open  his  mouth,  we  perceived  very  evident  traces  of  the  action  of  the 
poison  ; in  fact,  the  inner  surface  of  the  cheeks,  the  uvula,  the  velum  palati,  and  fauces,  were 
all  covered  with  ulcerations  of  a greyish  colour,  bordering  a little  on  yellow.  The  hoarseness 
of  the  voice,  an  acute  pain  along  the  oesophagus,  which  was  increased  during  deglutition,  in- 
duced us  to  think  that  the  upper  part  of  the  larynx  and  the  oesophagus  were  the  seat  of  lesions 
similar  to  those  described.  By  the  use  of  leeches,  cataplasms,  and  demulcents,  the  alarming 
gastric  symptoms,  such  as  nausea,  vomiting,  epigastric  pain,  had  considerably  diminished. 
The  features  however  were  very  sharp,  pulse  small  and  wiry,  and  from  ninety-two  to  ninety- 
six  ; at  the  end  of  two  or  three  weeks  he  thought  himself  sufficiently  wrell  to  leave  the  hos- 
pital, his  only  complaint  then  being  the  sensation  of  a tightness  or  constriction  towards  the 
middle  and  lower  portion  of  the  oesophagus.  At  his  departure  we  recommended  him  to  be 
particularly  exact  as  to  his  diet,  as  his  stomach  still  evinced  considerable  irritability.  Unfor- 
tunately, however,  he  had  a very  voracious  appetite,  and  notwithstanding  our  advice  to  him, 
he  indulgedjit.  In  three  weeks  after  he  returned  again  to  the  hospital,  and  stated  that  three  or 
four  days  after  he  had  returned  home,  the  pain  originally  felt  in  the  region  of  the  oesophagus 
and  stomach,  again  attacked  him,  and  also  the  nausea  and  vomiting,  accompanied  by  colic  and 
constipation.  He  was  now  very  much  emaciated  ; nausea,  vomiting,  sour  eructations,  and 
considerable  swelling  of  the  epigastric  region,  were  the  principal  symptoms  observed.  Tongue 
pale,  sufficiently  moist,  breath  fetid,  pulse  from  sixty-six  to  sixty-eight,  and  the  temperature  of 
the  skin  natural ; fifteen  leeches  were  applied  ; anodyne  cataplasms  to  the  epigastrium,  pills  of 
carbon  and  magnesia,  castor  oil,  which  was  vomited  instantly  after  being  taken.  Still  the 
epigastrium  became  more  and  more  tumefied,  and  the  tumefaction  presented  this  peculiarity, 
that  it  was  much  more  marked  in  the  left  hypochondrium,  where  there  existed  a sort  of  tumour, 
which  made  the  ribs  project;  this  was  situated  obliquely, towards  the  umbilical  region,  forming 
a curve,  wdth  its  convexity  to  the  left.  Percussion  yielded  to  a dull  sound,  and  there  was 
evident  fluctuation  in  the  abdominal  cavity.  Pressure  occasioned  pain.  The  strength  dimi- 
nished every  day,  and  the  gastric  symptoms  remained  nearly  unchanged.  There  was  evident 
effusion  into  the  peritoneum,  and  also  chronic  gastritis.  The  acute  pain  of  which  the  patient 
then  complained  in  the  abdomen,  inclined  us  to  suspect  the  existence  of  peritonitis.  The  pulse 
was  now  become  very  frequent  and  small,  tongue  frequently  became  dry,  and  the  features  were 
now  sharpened.  Calomel  and  opium  pills  were  now  given,  a blister  was  applied  over  the 
epigastrium,  mercurial  frictions  to  the  abdomen,  after  which,  to  our  surprise,  the  effusion  ulti- 
mately disappeared  altogether.  When  the  abdomen  was  now  collapsed,  we  still  observed  a 
projection  in  the  left  hypochondriacal  region.  The  nausea  and  some  slight  vomiting  still  con- 
tinued, and  the  emaciation  of  the  patient  went  on  increasing.  .Notwithstanding  the  vomiting 


DISEASES  OF  THE  ABDOMEN. 


251 


Atrophy  of  the  muscular  coat  of  the  stomach  may  also  coincide  with  a similar 
atrophy  of  the  other  coats.  Simultaneous  atrophy  of  the  mucous,  cellular  and 
muscular  membranes,  is  sometimes  carried  so  far,  that  over  an  extent,  which  is 
often  very  considerable,  namely,  over  the  great  cul-de-sac,  the  parietes  of  the 
stomach  present  the  appearance  of  a very  delicate  tissue,  formed  of  peritoneum 
alone,  on  which  some  vestiges  of  the  other  membranes  are  perceived  here  and 
there.  Such  cases  have  been  very  accurately  described  by  M.  Louis. 

The  different  morbid  changes  which  have  been  just  described,  do  not  form  with 
equal  frequency  at  all  periods  of  life.  Nothing  is  more  uncommon,  for  instance, 
than  to  observe  scirrhous  induration  of  the  gastric  cellular  tissue  before  the  age 
of  thirty-five  or  forty.  In  this  respect  the  following  case  seems  worth  re- 
porting. 


Case  4. — Scirrhus  of  the  stomach  in  a person  twenty-two  years  of  age;  first  symptoms  of  the 
disease  at  the  age  of  nineteen, 

A man,  twenty-two  years  of  age,  felt  at  the  age  of  nineteen  acute  pains  in 
the  epigastrium.  From  this  time  his  digestion  began  to  become  deranged  ; he 
was  annoyed  with  acid  eructations,  and  a disagreeable  sensation  of  we  ight 
towards  the  region  of  the  stomach,  as  soon  as  he  took  food : he  lost  flesh,  and 
became  emaciated  ; still  he  did  not  vomit.  At  length,  at  the  end  of  two  years, 

the  patient  still  called  for  solid  food,  and  expressed  an  insuperable  dislike  for  broths.  He  now 
again  determined  on  leaving  the  hospital,  having  recovered  some  little  strength,  the  abdominal 
effusion  having  disappeared,  and  he  himself  being  dissatisfied  at  the  small  quantity  of  food 
allowed  to  him,  when  he  expired  suddenly  about  three  months  after  he  had  swallowed  the 
poison. 

Post-mortem. — The  stomach  was  of  an  enormous  size.  It  filled  not  only  the  left  hypo- 
chondrium,  but  all  the  left  side  of  the  abdominal  cavity,  as  far  as  the  iliac  fossa.  This  was 
evidently  the  cause  of  the  tumefaction  observed  during  life.  When  an  incision  was  made  into 
the  parietes  of  this  immense  pouch,  there  issued  from  its  cavity  a sort  of  thick  fluid  very  like 
chocolate,  exhaling  a penetrating  acrid  odour.  The  quantity  of  the  contents  of  the  stomach 
may  be  estimated  at  nearly  two  litres.  Notwithstanding  this  enormous  dilatation  of  the 
stomach,  its  parietes  were  attenuated  only  in  one  part,  particularly  towards  the  great  tuber- 
osity. The  pyloric  portion  of  the  gastric  mucous  membrane  was  of  a bright  red  colour, 
owing  to  a very  fine  dotted  injection  uniformly  diffused  over  the  part.  This  portion,  con- 
trasted with  that  which  lined  the  great  cubde-sac,  which  was  brownish,  slate-coloured,  and 
much  less  injected.  In  this  latter  portion  the  mucous  membrane  was  softened,  and  completely 
destroyed  in  several  points.  Very  near  to  the  pylorus  we  observed  the  remainder  of  two  oval 
ulcerations,  situate  one  before  the  other.  Their  bottom  was  smooth  and  surrounded  with  a 
thick  edge,  about  one-fourth  of  a line  in  depth,  continuous  with  this  same  bottom.  The  pro- 
cess of  cicatrisation  was  very  far  advanced  in  these  two  ulcerations ; it  was  more  advanced 
in  another  ulcer  which  was  at  the  distance  of  about  an  inch  from  the  two  preceding,  having  a 
rounded  form  and  being  an  inch  in  diameter ; the  bottom  of  this  ulcer,  formed  of  injected 
cellular  tissue,  was  surrounded  by  a sort  of  puftiness.  The  orifice  of  the  pylorus  formed  a 
kind  of  funnel,  the  duodenal  opening  of  which  was  scarcely  a line  in  diameter.  Around  this 
orifice  the  parietes  of  the  stomach  were  indurated  and  thickened,  the  induration  and  thicken- 
ing being  continued  towards  the  duodenum  to  the  extent  of  about  one  inch  and  a half.  The 
thickness  of  the  parietes  of  the  duodenum  and  pyloric  circle  was  from  four  to  five  lines.  The 
surface  of  the  section  made  in  the  indurated  and  hypertrophied  parietes  was  of  a greyish 
white,  shaded  with  a bluish  tint ; the  tissue  of  these  parietes  presented  a Iardaceous  appearance, 
grated  somewhat  under  the  scalpel  when  cut  into,  and  we  there  found,  in  a word,  all  the 
characters  of  scirrhus  of  the  stomach.  In  the  portion  of  the  duodenum  thus  transformed  into 
scirrhous  matter,  the  presence  of  the  mucous  membrane  was  still  recognised.  The  rest  of  the 
digestive  tube  presented  no  perceptible  alteration.  It  was  merely  diminished  considerably  in 
size,  and  was  really  atrophied.  There  was  a tolerable  quantity  of  fseces  of  moderate  consist- 
ence in  the  large  intestine. 

In  the  lower  third  of  the  oesophagus  we  observed  several  rounded  depressions,  the  bottom  of 
which  was  smooth  and  polished,  surrounded  by  a small  edge,  which  was  from  three  to  four 
lines  in  diameter.  These  depressions  appeared  to  us  to  be  cicatrised  ulcerations.  The  ceso- 
phagseal  mucous  membrane  was,  in  other  parts,  of  a pale  or  greyish  white. 


252 


ANDRAL’S  MEDICAL  CLINIC. 


he  began  to  experience  frequent  nausea,  and  to  vomit  his  food  and  drink  from 
time  to  time.  This  vomiting,  which  at  first  occurred  but  rarely,  became  more 
and  more  frequent ; it  usually  occurred  three  or  four  hours  after  meals.  When 
the  patient  entered  the  Charite,  he  was  in  a frightful  state  of  emaciation ; he 
vomited  almost  every  day ; a well  defined  tumour  was  felt  in  the  epigastrium, 
to  the  right  of  the  xiphoid  cartilage.  The  patient,  after  a short  stay  in  the 
hospital,  pined  away  and  died.  He  had  presented  all  the  general  and  local 
symptoms  of  an  organic  affection  of  the  stomach  in  its  most  simple  form.  The 
post-mortem  examination  justified  our  diagnosis.  The  pyloric  portions  of 
the  stomach,  and  the  pylorus  itself,  were  found  to  have  degenerated  into  a scir- 
rhous mass,  with  an  admixture  of  encephaloid  matter  not  softened. 

This  case,  which  is  principally  important  in  reference  to  the  age  of  the  sub- 
ject, presents  other  circumstances  well  deserving  attention. 

The  nausea  and  vomiting  did  not  commence  till  two  years  after  the  appear- 
ance of  the  other  symptoms,  such  as  deranged  digestion,  acid  eructations,  etc. ; 
those  lancinating  pains  in  the  epigastrium,  which  are  either  entirely  absent,  or 
very  slight  in  so  many  persons,  were  always  very  severe  in  our  young  patient. 
Was  the  nervous  system,  as  being  more  active  in  him  in  consideration  of  his 
youth,  more  seriously  affected,  and,  consequently,  did  he  feel  the  pain  more 
acutely  ? Be  that  as  it  may,  the  absence  of  vomiting  should  not  make  us  dis- 
believe in  the  existence  of  a cancer  of  the  stomach  ; for  considerable  experience 
has  taught  us  that  vomiting  is  not  an  essential  symptom  of  this  disease  ; that 
it  may  not  show  itself,  principally  in  those  cases  where  the  cancer  attacking 
the  body  of  the  stomach,  the  two  openings  of  this  viscus  remain  free. 

The  bloodvessels  of  the  stomach  present  some  remarkable  changes  in  chronic 
gastritis.  For  instance,  we  often  find  beneath  the  softened  mucous  membranes 
veins  of  a remarkably  large  size,  evidently  dilated,  and  which  have  become 
as  it  were  varicose.  The  same  change  is  observed  in  several  other  parts 
wherein  an  inflammatory  process  is  going  on  for  a long  time  ; thus  large  vari- 
cose veins  are  often  seen  around  old  ulcers  of  the  lower  extremities.  This 
dilated  state  of  the  veins  sometimes  continues  for  a longer  or  shorter  time  after 
the  inflammation  has  ceased.  In  such  cases  it  seems  to  be  a phenomenon  alto- 
gether passive,  like  dilatation  of  the  veins  of  the  conjunctiva  after  some  cases  of 
ophthalmia.  But  this  dilatation  may  also  be  active,  accompanied  by  thicken- 
ing of  the  parietes  of  the  vessel,  and  produced  by  a real  process  of  inflamma- 
tion, propagated  from  the  mucous  membrane  to  the  capillaries,  which  pass 
through  it,  and  from  thence  to  the  great  venous  trunks,  which  bring  back  the 
blood  into  the  torrent  of  the  circulation.  The  very  interesting  facts  published 
by  Dr.  Ribes,  have  shown  thatin  certain  cutaneous  inflammations,  inflammation 
of  the  veins  acts  an  important  part;  I have  endeavoured  to  satisfy  myself  as  to 
whether  the  same  thing  took  place  in  certain  cases  of  inflammation  of  mucous 
membrane,  and  more  particularly  with  respect  to  the  gastric  mucous  membrane. 
The  following  phenomena  presented  themselves  in  two  cases;  on  laying  open 
some  large  and  dilated  veins  which  ramified  beneath  the  mucous  membrane, 
which  was  red  and  soft  in  one  case,  and  brown  and  hypertrophied  in  the  other, 
I detected  considerable  thickening  of  their  parietes,  which  opposed  a sort  of  re- 
sistance to  the  scalpel,  appeared  as  it  were  hard  to  the  touch,  and  did  not  col- 
lapse after  they  had  been  divided.  Now,  we  know  that  this  thickening  of  the 
mucous  parietes,  with  or  without  dilatation  of  their  cavity,  is  one  of  the  charac- 
ters of  chronic  phlebitis.  In  another  individual  whose  stomach  was  the  seat  of 
extensive  ulceration,  surrounded  with  soft  and  reddish  vegetations  formed  at  the 
expense  of  the  mucous  membrane,  large  veins  were  seen  in  great  numbers 
around  this  ulceration;  they  were  situated  in  the  sub-mucous  cellular  tissue. 
One  of  them  was  remarkably  hard,  and  its  appearance  resembled  that  of 
certain  small  veins  of  the  extremities  which  have  been  obliterated  by  old  clots. 


DISEASES  OF  TI1E  ABDOMEN. 


253 


It  was  distended  and  filled  with  a solid  mass  of  dark  red  colour,  like  wine  lees, 
mixed  with  a more  liquid  substance  of  a purulent  appearance.  On  tracing  this 
vein  as  near  as  possible  to  the  ulcer,  it  was  seen  that  the  venules  which  went 
to  form  it  were  hard  like  itself,  obstructed  by  solid  matter,  and  resembling  small 
nodosities. 

The  part  which  the  bloodvessels  of  the  stomach  sometimes  take  in  its  inflam- 
mation may  also  be  proved  by  other  facts.  These  facts  are  those  in  which 
bloodvessels  have  been  found  ruptured,  and  more  or  less  open  at  the  bottom  of 
an  ulcer.  What  can  be  the  cause  of  this  rupture  of  the  vessels  ? The  same 
no  doubt  as  that  which  has  caused  the  successive  destruction  of  the  other  tis- 
sues, and  which  occasioned  the  formation  of  an  ulcer.  Thus,  the  vessels  which 
ramify  on  the  surface  of  a pulmonary  cavity,  are  perforated  equally  with  those 
contained  in  the  bands  which  pass  through  it.  We  know,  besides,  that  in  these 
vessels  the  adhesive  is  much  more  common  than  the  ulcerative  inflammation, 
whence  it  happens  that  their  obliteration  is  much  more  common  than  their 
perforation.  Does  the  same  thing  occur  around  and  at  the  bottom  of  chronic 
ulcerations  of  the  stomach  ? It  is  a fact  worth  remarking,  that  in  some  cases 
where  vessels  have  been  found  with  very  open  mouths  at  the  bottom  of  one  of 
these  ulcerations,  there  had  been  no  hematemesis  during  life,  nor  any  blood 
effused  into  the  stomach. 

The  lymphatic  system  of  the  stomach  does  not  always  escape  the  effects  of 
chronic  inflammation  of  this  organ.  In  this  system  we  have  to  consider,  first, 
the  vessels,  secondly,  the  glands,  into  which  these  vessels  enter,  and  from  which 
they  pass. 

I no  longer  reckon  those  cases  where,  in  different  points  of  the  intestine,  I 
found  lymphatic  vessels  filled  with  pus,  or  a substance  of  more  consistence  than 
ordinary  pus,  friable,  and  as  it  were  of  a tuberculous  character,  passing  from  an 
ulcer ; these  lymphatic  vessels,  thus  distended,  entered  the  mesentery,  and 
sometimes  disappeared  there  insensibly,  whilst  sometimes  they  might  be 
traced  as  far  as  a gland.  In  several  cases  there  was  not  only  distension  of  the 
vessel  by  foreign  matter,  but  there  was  also  very  evident  thickening  of  its 
parietes,  which  had  lost  their  usual  transparence.  Once  only  I found  a similar 
state  of  the  lymphatics  in  the  stomach.  One  of  these  vessels,  filled  with  whitish 
matter,  passed  out  from  an  ulcer  situate  towards  the  middle  of  the  great  curva- 
ture of  the  stomach,  passed  all  along  this  curvature,  and  ceased  to  be  visible 
towards  the  great  cul-de-sac. 

The  ganglions,  which  receive  several  of  the  lymphatic  vessels  of  the  stomach, 
and  which  exist,  as  every  one  knows,  along  its  two  edges,  appear  less  liable  to 
become  engorged  after  acute  or  chronic  gastritis,  than  the  glands  of  the  mesen- 
tery are  after  enteritis.  However,  in  some  cases  of  chronic  gastritis,  they  are 
found  to  have  become  very  much  enlarged,  and  to  form  considerable  tumours. 
Some  of  the  phenomena  and  of  the  symptoms,  which  were  supposed  to  depend 
on  the  stomach,  have  sometimes  depended  on  these  tumours.  Thus,  during 
life  they  may  be  appreciated  by  pressing  it  over  several  points  of  the  epigas- 
trium, and  may  present  the  same  varieties  of  position,  form,  size,  and  mobility, 
as  the  tumours  belonging  to  the  stomach  itself.  At  other  times,  it  is  the  gan- 
glions situate  either  along  the  diaphragmatic  edge  of  the  stomach,  or  principally 
behind  the  stomach,  in  the  posterior  epiploic  cavity,  which  acquire  an  enor- 
mous size,  at  the  same  time  that  their  tissue  undergoes  different  species  of  alte- 
rations. They  may  then  displace  the  stomach,  push  it  forward,  compress  it 
between  them  and  the  abdominal  parietes,  and  contribute  as  much  to  the  diffi- 
culty of  digestion,  as  chronic  inflammation  of  the  stomach  itself.  At  other  times 
the  pylorus  is  found  surrounded,  compressed,  actually  obstructed  by  these  gan- 
glions, transformed  into  large  tumours;  thence  arises  vomiting,  such  as  is  ob- 
served when,  for  instance,  considerable  induration  of  the  submucous  cellular 
22 


254 


ANDRAL’S  MEDICAL  CLINIC. 


tissue  of  the  pyloric  ring,  and  the  parts  around  it,  opposes  the  free  passage  of 
the  food  from  the  stomach  into  the  duodenum. 

Among  the  anatomical  structures  of  the  stomach,  which  have  been,  hitherto, 
too  much  neglected  in  the  anatomical  study  of  the  diseases  of  this  organ,  we 
must  place  the  nerves.  There  is  no  doubt  but  that  more  than  one  gastric  affec- 
tion is  occasioned  by  alterations  of  them.  But  is  this  alteration  appreciable 
by  anatomical  investigation  ? To  this  I can  answer,  that  I have  many  times 
dissected  with  great  care  the  pneumogastric  nerves  in  their  trunks  and  ramifi- 
cations on  the  two  surfaces  of  the  stomach,  as  also  the  numerous  branches  which 
it  receives  from  the  great  sympathetic ; I have  dissected  them  both  in  healthy 
stomachs,  as  also  in  those  which  presented  most  of  the  changes  already  described ; 
and  have,  hitherto,  been  able  to  obtain  but  mere  negative  results  ; and  in  cases 
of  morbid  alteration  of  the  stomach,  which  differed  most  widely  from  each  other, 
I have  not  found  any  appreciable  difference  in  the  colour,  size,  or  consistence  of 
the  nerves  distributed  to  them.  By  this,  I do  not  mean  to  say,  that  these  nerves 
are  always  exempt  from  appreciable  alteration  ; but  as  I have  examined  fifty-three 
bodies  at  the  Charite,  in  reference  to  this  subject,  without  discovering  any  thing, 
I think  myself  warranted  in  concluding,  first,  that  these  alterations  are  uncom- 
mon ; secondly,  that  they  are  not  necessarily  connected  with  any  of  the  numerous 
organic  alterations  with  which  the  stomach  may  be  affected.  However,  experi- 
ence does  not  suffer  us  to  doubt,  that  though  the  alterations  of  the  nerves  of  the 
stomach  are  not  in  general  of  such  a nature  as  that  they  can  be  appreciated  by 
dissection,  these  alterations  are  still  not  the  less  real  and  frequent.  There  is  no 
doubt  but  that,  on  the  one  hand,  the  numerous  sympathies  transmitted  by  the 
stomach  to  the  different  organs,  are  transmitted  by  means  of  its  nerves,  which  are 
so  remarkable  for  their  distribution  and  their  numerous  connexions;  neither  is 
there  any  doubt  but  that,  on  the  other  hand,  among  the  infinitely  varying  modi- 
fications of  function  which  the  stomach  may  present,  and  which  simulate  more 
or  less  completely  the  symptoms  of  acyte  or  chronic  gastritis,  several  depend  on 
a vitiated  influence  of  the  nervous  centres  on  the  stomach ; thence,  in  some  per- 
sons, we  observe  various  disturbances  of  digestion ; in  others  vomiting;  in  others 
again  epigastric  pain,  etc. 

Chronic  inflammation  of  the  stomach,  whatever  be  the  form  which  it  has 
assumed,  may  terminate  in  gangrene,  but  much  less  frequently  than  has  been 
stated.  The  case  wherein  I have  most  frequently  met  this  gangrene,  is  that  where 
the  stomach  was  the  seat  of  an  old  ulceration,  with  fungosities  around  it  and  in 
its  bottom.  It  was  this  ulceration  itself  which  the  gangrene  had  attacked;  it  was 
then  found  covered  with  a grey  or  blackish  detritus,  which  was  raised  like  pap 
by  the  scraping  of  the  scalpel,  and  which  exhaled  a most  foetid  odour.  Towards 
the  termination  of  life  there  was  a sudden  prostration  of  the  strength ; the  coun- 
tenance had  rapidly  assumed  a cadaveric  appearance;  frequent  hematemesis  had 
taken  place ; this  group  of  symptoms  had  probably  coincided  with  the  period 
when  the  ulceration  of  the  stomach  had  commenced  to  be  attacked  with  gan- 
grene. Such  is  also  the  termination  of  several  ulcerations  and  degenerations  of 
the  neck  of  the  uterus;  there  is  then  also  very  often  a great  resemblance  between 
the  alteration  of  the  stomach  and  that  of  the  uterus.  It  is  in  this  way  also,  that 
in  more  than  one  phthisical  patient,  gangrene  comes  to  attack  the  parietes  of 
cavities,  which  are  found  to  become  changed  into  a black  and  foetid  mass  of 
corruption. 

I have  much  more  rarely  found  the  stomach  attacked  with  gangrene,  when  it 
had  not  been  previously  ulcerated.  Sometimes,  however,  I have  found  portions 
of  mucous  membrane  gangrenous,  and  changed  into  eschars  over  tumours  formed 
by  indurated  sub-mucous  cellular  tissue. 

The  stomach,  when  attacked  with  chronic  inflammation,  undergoes,  in  its  form 
and  size,  various  modifications,  which  may  be  appreciated  during  life  through 


DISEASES  OF  THE  ABDOMEN. 


255 


the  abdominal  parietes.  I shall  here  consider  chiefly  the  changes  of  size  which 
it  may  present.  The  cases  in  which  the  cavity  of  a hollow  viscus  is  seen  to 
become  very  much  enlarged  beyond  its  natural  condition,  are  numerous  and 
varied,  with  respect  to  the  causes  which  occasion  this  enlargement.  Thus  the 
dilatation  sometimes  takes  place  in  consequence  of  an  obstacle  at  the  orifice, 
through  which  the  liquids  introduced  into  the  cavity  of  the  stomach  should  na- 
turally pass  out;  this  is  sometimes  the  case  with  the  heart,  urinary  bladder,  gall- 
bladder, <fec.  The  parietes  of  the  cavity  of  these  organs  then  either  retain  their 
natural  thickness,  or  become  hypertrophied,  or  are  attenuated.  Sometimes, 
without  any  obstacle  opposing  the  free  exit  of  the  fluids,  such  a dilatation  is 
observed  to  take  place,  the  parietes  of  the  cavity  still  presenting  one  of  the 
three  conditions  which  existed  in  the  preceding  case.  In  this  case,  all  the 
hollow  organs  may  be  found,  the  heart,  bladder,  arteries,  veins,  bronchi,  &c. 
Like  to  all  these  organs,  the  stomach  may  be  very  much  dilated,  may  become 
large  enough  to  fill  all  the  abdominal  cavity,  whether  there  exists  an  obstacle 
at  the  pylorus,  which  is  the  most  common  case,  or  whether  the  parietes  of 
the  pyloric  region  present  considerable  induration  of  the  cellular  tissue  with 
atrophy  of  the  muscular  coat,  the  pyloric  orifice  at  the  same  time,  far  from 
being  contracted,  being  found,  on  the  contrary,  wider  than  natural;  or  whether, 
in  a word,  as  is  the  most  uncommon  case,  the  parietes  of  the  stomach  present 
no  other  change  except  injection,  or  softening  of  the  mucous  membrane. 

Thus,  then,  of  these  three  cases,  there  is  but  one  in  which  the  dilatation  of 
the  stomach,  and  the  great  enlargement  of  its  cavity  co-exist,  with  an  obstacle 
to  the  free  passage  of  food  from  the  stomach  into  the  duodenum.  It  is  possible, 
however,  as  I shall  have  an  opportunity  of  stating  presently,  that,  in  the  second 
case,  where  the  pyloric  orifice  is  dilated  instead  of  being  narrowed,  atrophy  of 
the  muscular  membrane,  at  this  part  of  the  stomach,  may  be  as  powerful  a 
cause,  as  some  tumours  of  the  pylorus,  to  prevent  the  free  exit  of  food  from 
the  stomach. 

The  three  following  cases  will  furnish  remarkable  instances  of  dilatation  of 
the  stomach  carried  to  an  extreme  degree. 

In  the  first  of  these  cases,  there  i6  an  obstacle  at  the  pylorus  which  opposes 
the  passage  of  the  food  from  the  stomach  into  the  duodenum;  in  the  second,  it 
is  the  latter  intestine  which  is  the  seat  of  the  obstacle ; in  the  third,  there  is  not 
an  obstacle  at  any  point  to  the  free  course  of  the  food,  and  still,  notwithstand- 
ing this  absence  of  mechanical  causes,  the  stomach  had  undergone  enormous 
dilatation. 

Case  5. — Great  dilatation  of  the  stomach,  which  filled  the  entire  abdomen  ; induration  of  the 

parts  of  its  pyloric  portion,  with  atrophy  of  the  muscular  tunic,  the  usual  size  of  the  pylorus 

still  remaining. 

A woman,  sixty-five  years  old,  very  much  emaciated,  began  to  evince,  to- 
wards the  month  of  June,  the  symptoms  of  an  organic  affection  of  the  stomach? 
difficult  digestion,  alternation  of  voracious  appetite  and  complete  anorexia,  acid 
eructations,  nausea,  frequent  vomiting  for  several  hours  after  meal,  pain  in  the 
epigastrium. 

These  symptoms  became  every  day  worse.  In  the  March  of  the  following 
year  she  entered  the  Charite.  She  was  then  reduced  to  the  last  stage  of  marasmus. 
The  stomach  might  be  distinctly  traced  through  the  abdominal  parietes;  it  evidently 
occupied  the  principal  portion  of  the  abdomen.  Its  colic  edge  rested  immediately 
on  the  pubis ; its  diaphragmatic  edge  described  a curve,  the  concavity  of  which 
looked  upwards,  and  which,  proceeding  from  the  epigastrium,  descended  as  far  as 
the  umbilicus,  then  reascended  towards  the  right  hypochondrium.  She  felt 
towards  the  part  where  the  pylorus  might  be  supposed  to  lie,  an  habitual  pain, 
which  at  intervals  became  more  severe.  She  vomited  almost  every  forty-eight 


256 


ANDRAL’S  MEDICAL  CLINIC. 


hours  a great  quantity  of  brownish  liquid.  After  vomiting  the  tumour  formed 
by  the  stomach  diminished,  but  did  not  disappear.  The  vomiting  was  without 
any  effort,  almost  as  a simple  regurgitation.  The  patient  was  often  desirous  to 
get  food  ; but  she  had  scarcely  swallowed  a few  mouthfuls,  when  she  was  satis- 
fied ; there  then  came  a sensation  of  insupportable  bitterness  in  her  mouth.  She 
continued  passing  a great  quantity  of  gas  by  the  mouth. 

The  appearance  of  the  tongue  was  natural ; thirst  very  moderate,  stools 
scanty  ; pulse  not  at  all  frequent,  and  very  weak  ; the  skin  dry,  and  not  at  all 
hot.  The  origin  of  the  disease  could  not  be  referred  to  any  appreciable  cause. 
This  woman  sunk  rapidly,  and  after  being  about  fifteen  days  in  the  hospital,  her 
features  changed,  her  pulse  ceased  to  beat,  her  extremities  became  cold,- and  she 
expired  without  a struggle,  having  retained  the  free  use  of  her  intellects  to  the 
last  moment. 

Post-mortem.  The  brain  and  lungs  were  sound.  On  raising  the  abdominal 
parietes,  we  perceived  the  stomach  occupying  all  the  entire  cavity.  It  descended 
at  first  vertically  from  the  epigastrium  to  near  the  left  iliac  fossa ; it  then  turned 
obliquely  from  left  to  right,  and  from  above  downwards  towards  the  right  iliac 
fossa;  within  this  space  the  great  curvature  was  concealed  by  the  pubis,  and 
rested  on  the  uterus;  it  then  ascended  towards  the  right  hypochondrium,  where 
it  was  continued  with  the  duodenum.  The  remainder  of  the  intestinal  canal 
was  concealed  by  the  stomach,  with  the  exception  of  some  convolutions  of  the 
small  intestine,  which  occupied  the  right  flank,  and  of  the  sigmoid  flexure  of 
the  colon.  The  stomach  contained  an  enormous  quantity  of  brown  fluid,  simi- 
lar to  that  which  had  been  vomited  during  life.  The  internal  surface  was  every 
where  perfectly  white,  but  the  mucous  membrane  was  also  very  soft  on  every 
part.  To  the  extent  of  four  fingers’  breadth  on  this  side  of  the  pylorus,  this 
membrane  no  longer  existed. 

Where  the  solution  of  continuity  of  the  mucous  membrane  commenced,  it 
formed  an  irregular  whitish  swelling  ( bourrelet ).  The  bottom  of  the  ulcer  so- 
formed,  consisted  of  cellular  tissue,  which  was  four  or  five  times,  at  least,  its 
natural  thickness,  and  was  divisible  by  the  scalpel  into  a tissue  of  a pearly 
white  appearance.  The  free  surface  presented  a blackish  grey  colour.  Over 
this  same  extent  no  trace  of  muscular  fibre  was  any  longer  observable.  The 
pyloric  aperture  was  still  large  enough  readily  to  admit  the  extremity  of  the 
index  finger.  The  remainder  of  the  intestinal  canal  was  healthy. 

How  are  we  to  explain,  in  this  case,  the  accumulation  of  food  in  the  stomach,, 
and  its  enormous  distension,  the  pyloric  orifice  being  free,  and  even  larger  than 
natural  ? This  orifice,  when  observed  in  the  dead  body,  is  really  closed,  and  a 
certain  resistance  must  be  overcome  in  order  to  introduce  the  extremity  of  the 
little  finger  into  it.  If  we  examine  it  in  the  living  body,  we  also  see  that  it 
remains  habitually  closed,  like  the  sphincters  of  the  bladder  and  rectum.  But 
during  digestion,  and  when  the  cbymified  food  has  passed  into  the  duodenum, 
a new  phenomenon  presents  itself.  The  muscular  fibres  of  the  stomach  pre- 
sent a very  manifest  motion  of  contraction,  which,  commencing  towards  the 
middle  of  the  body  of  the  stomach,  is  continued  as  far  as  the  first  curve  of  the 
duodenum  ; this  contraction  changes  the  state  of  the  pylorus,  overcomes  its 
resistance,  which  is  entirely  passive,  so  that  the  muscular  contraction  which  has 
been  just  described,  is  at  least  one  of  the  principal  causes,  if  not  the  only  one, 
which  propels  the  chyme  into  the  duodenum.  Hence  it  follows,  that  if  in  the 
pyloric  portion  of  the  stomach  there  be  no  longer  any  fleshy  fibres,  one  of  the 
most  powerful  causes  of  the  expulsion  of  the  food  ceases  to  act,  and  the  latter 
passes  into  the  duodenum,  not  without  considerable  difficulty.  Such  is  the 
mode  of  accounting  for  the  fact  in  question,  supposing  it  to  be  granted  that  the 
enormous  dilatation  of  the  stomach  recognises  for  its  cause  the  distension  it 
suffers  from  the  unusual  accumulation  of  a great  quantity  of  food.  But  is  this 


DISEASES  OF  THE  ABDOMEN. 


257 


cause  as  powerful  as  has  been  said?  We  may  remark  on  the  one  hand,  that 
such  a dilatation  may  take  place  without  there  being  any  appreciable  cause  to 
* prevent  the  passing  of  the  food  into  the  duodenum.  (See  the  next  case.)  And 
on  the  other  hand,  it  may  be  observed,  that  very  considerable  obstacles  often 
exist  at  the  pylorus  without  the  stomach  being  perceptibly  dilated. 

Case  6. — Cancer  of  the  duodenum  ; cicatrix  in  the  stomach  ; dilatation  of  the  latter  organ, 
the  colic  edge  of  which  almost  touches  the  pubis. 

A woman,  seventy-four  years  of  age,  entered  the  Pitie  on  the  1st  of  Novem- 
ber, 1832.  She  had  been  for  a long  time  labouring  under  indigestion,  and 
vomited  from  time  to  time.  She  remained  for  twelve  days  in  the  hospital ; 
during  this  time  she  did  not  vomit ; her  tongue  was  constantly  dry,  and  of  a 
smooth,  uniform  red  appearance.  She  gradually  became  weaker,  and  died. 

Post-mortem.  The  stomach  had  attained  an  enormous  size.  It  occupied 
almost  the  entire  abdomen  ; its  colic  edge  was  separated  from  the  pubis  only 
by  a space  of  about  two  inches.  The  great  cul-de-sac  adhered  to  the  abdomi-* 
nal  parietes  by  old  cellular  bands.  It  contained  about  a litre  of  a greyish  liquid. 
Its  mucous  membrane  was  everywhere  pale,  and  of  good  consistence.  Beneath 
it  the  cellular  tissue  was  remarkably  thick,  and  the  muscular  coat  was  evidently 
hypertrophied.  Thus  the  dilatation  of  the  stomach  had  not  been  purely  pas- 
sive. Towards  the  great  cul-de-sac  an  extraordinary  puckering  of  it  coats  was 
observed:  the  fasciculi  of  the  muscular  membrane  terminated  as  so  many 
radii  in  a white  and  thick  point,  above  which  the  mucous  membrane  was,  as 
it  were,  puckered.  This  change  of  structure  resembled  the  cicatrix  of  an  old 
ulcer. 

In  the  duodenum,  two  inches  beyond  the  pylorus,  there  existed  a cancerous 
vegetation  which  went  all  round  the  intestine  like  a ring  ; it  was,  as  it  were,  a 
second  pylorus,  which  afforded  but  a very  narrow  passage  to  the  contents  of  the 
intestine.  The  ductus  choledochus,  which  was  considerably  dilated,  opened 
into  this  cancerous  mass. 

In  the  jejunum  and  ileum  a general  slate-coloured  tint  of  the  mucous  mem- 
brane was  observed.  The  termination  of  the  ileum  and  the  large  intestine  were 
filled  with  a blackish-grey  substance,  resembling  clay.  Reddish  bands  appeared 
on  the  internal  surface  of  the  colon.  The  tissue  of  the  liver  was  firm,  and  of  a 
bright  red  colour  ; the  spleen  was  small  and  dense.  The  left  kidney  contained 
some  small  black  calculi,  lodged  in  cysts,  within  the  cortical  substance ; around 
them  was  observed  a matter  equally  thick,  but  soft.  Two  other  small  calculi 
were  found  in  one  of  the  calices. 

Case  7. — Very  considerable  dilatation  of  the  stomach,  the  colic  edge  of  which  touched  the 

pubis,  without  any  other  alteration  of  its  parietes  except  a little  softening  of  the  mucous 

membrane  towards  the  great  cul-de-sac. 

A woman,  twenty-three  years  of  age,  who  had  always  enjoyed  good  health, 
left  the  provincial  town  in  which  she  had  resided  in  consequence  of  a reverse 
of  fortune,  and  came  to  reside  with  her  family  to  Paris.  Her  health  soon 
became  perceptibly  changed,  her  appetite  became  diminished,  her  digestion 
became  difficult,  and  towards  the  month  of  February,  1821,  after  a fright  which 
occasioned  long  continued  syncope,  she  began  to  vomit  both  her  meat  and  drink. 
She  usually  did  not  throw  them  up  till  several  hours  after  swallowing  them  ; 
however,  she  became  emaciated,  and  weakened  gradually. 

Leeches  were  applied  over  the  epigastrium ; magnesia,  and  various  antispas- 
modic  medicines  were  given.  From  the  month  of  December  the  vomiting 
became  more  frequent,  the  strength  diminished  rapidly,  and  the  menses  stopped. 
From  this  time  she  gave  up  her  occupation.  She  entered  the  Charite,  February 
22* 


258 


ANDKAL’S  MEDICAL  CLINIC. 


14,  1842,  and  presented  the  following  state  ; last  stage  of  marasmus,  no  com- 
plexion ; vomiting  of  both  solid  and  liquid  food,  more  or  less,  immediately  after 
its  being  taken  into  the  stomach  ; slight  pain  in  the  epigastrium,  which  was  soft 
and  presented  no  perceptible  tumour,  neither  did  any  other  part  of  the  abdomen 
present  any  ; appearance  of  the  tongue  natural,  habitual  constipation,  pulse  very 
weak  and  slightly  frequent,  skin  dry  and  not  at  all  hot,  breathing  free. 

This  patient  did  not  present  any  new  symptom  up  to  the  commencement  of 
March  ; the  demulcent  drinks  given  to  her  were  all  rejected  ; neither  could  she 
retain  the  light  food  allowed  her  from  time  to  time.  On  the  12th  of  March  the 
pulse  became  accelerated,  the  tongue  dry,  and  she  died  on  the  14th  of  March. 

Post-mortem.  — A little  serum  was  found  in  each  lateral  ventricle.  The 
pleura  costalis  and  pulmonalis  were  connected  by  long  and  dense  cellular  bands. 
The  stomach,  which  was  very  much  dilated,  covered  most  of  the  abdominal 
viscera;  its  colic  edge  touched  the  pubis  ; it  was  the  great  cul-de-sac  that  was 
most  dilated.  The  cavity  of  the  stomach  was  filled  by  a greenish  yellow  liquid  ; 
its  internal  surface  presented  a slight  rose  tint,  marbled  in  some  points  : towards 
the  spleen  it  was  whiter;  also  a portion  of  mucous  membrane,  about  the 
size  of  the  palm  of  the  hand,  was  very  much  softened,  and  might  be  raised 
like  a pap  by  slight  scraping,  in  every  other  part  it  was  of  the  natural  consist- 
ence. The  parietes  of  the  stomach  were  in  general  thin  and  readily  torn  ; the 
muscular  layer  was  very  much  attenuated.  The  small  intestines,  which  were 
very  much  contracted,  like  a dog’s  intestines,  were  almost  entirely  lodged  in  the 
cavity  of  the  lesser  pelvis  ; their  internal  surface  was  pale.  The  ascending  colon 
occupied  its  ordinary  place.  The  transverse  colon  had  followed  the  great  curva- 
ture of  the  stomach,  and  was  situate  behind  it ; its  internal  surface  presented  to 
the  extent  of  about  four  fingers  breadth  a violet  red  colour,  residing  in  the 
mucous  membrane,  which  was  a little  thickened.  Some  red  patches  of  the  same 
kind  were  observed  in  the  descending  colon  ; in  every  part  this  intestine  was  very 
much  contracted.  The  sigmoid  flexure  of  the  colon,  and  the  rectum,  which 
presented  no  alteration,  were  filled  with  hard  faeces.  Thus  there  was  no 
diarrhoea,  though  several  portions  of  the  large  intestine  were  evidently  inflamed. 
The  liver,  which  was  considerably  enlarged,  extended  on  the  left  as  far  as  the 
spleen  ; it  pressed  the  diaphragm  as  far  as  the  fifth  rib.  lnferiorly  it  passed  a 
little  beyond  the  edge  of  the  false  ribs  ; its  tissue  was  healthy.  When  the  ob- 
stacle to  the  passage  of  its  contents  exists  in  any  other  point  of  the  intestine,  we 
equally  see  the  portions  of  the  digestive  tube  situated  above  the  contracted  part 
more  or  less  dilated.  Instances  of  this  will  be  seen  in  the  two  following  cases, 
the  details  of  which  we  thought  it  right  to  present,  in  consequence  of  the  interest 
which  they  possess  in  other  respects  also. 

Case  8. — Scirrhous  degeneration  both  of  the  parietes  of  the  stomach  and  of  the  colon — Symp- 
toms of  intestinal  strangulation — Considerable  dilatation  of  the  portion  of  the  large  intestine 

above  the  contraction — Depression  of  one  of  the  cerebral  hemispheres  by  a fibrous  tumour. 

A woman,  forty-eight  years  of  age,  entered  the  Charite  on  the  6th  of  October. 
For  about  twelve  months  previous  to  this  time  her  health  began  to  become  de- 
ranged. Her  digestion  was  often  painful,  though  she  did  not  vomit ; she  fre- 
quently experienced  the  most  complete  disrelish  for  food  of  every  kind ; since 
the  same  period  she  scarcely  ever  had  an  alvine  evacuation,  except  by  means  of 
lavements.  She  had  gradually  lost  flesh  and  strength  ; still  she  continued  her 
ordinary  occupation  ; but  on  the  20th  of  September  her  abdomen  became  painful 
and  tympanitic;  on  the  followingday  obstinate  constipation  set  in,  which  could 
not  be  overcome  by  lavements  ; the  latter  was  passed  immediately  after  being 
taken,  and  brought  nothing  with  them.  The  constantly  increasing  size  of  the 
abdomen  alarmed  the  patient,  and  determined  her  on  entering  the  hospital. 

When  we  saw  her  for  the  first  time  her  countenance  was  pale,  and  her  fea- 


DISEASES  OF  THE  ABDOMEN. 


259 


tures  sharp.  She  complained  of  general  pain  over  the  abdomen,  which  was 
more  severe  in  the  right  flank,  and  was  increased  by  pressure.  The  abdomen, 
which  was  enormously  distended,  sounded  like  a drum  when  struck.  The 
patient  began  to  vomit  for  the  first  time  during  the  night.  The  appearance  of 
the  tongue  was  natural  ; a considerable  quantity  of  gas  was  passed  by  the  mouth, 
none  by  the  anus.  There  had  been  no,  alvine  evacuation  for  the  last  seven  or 
eight  days.  The  breathing  was  short  and  hurried;  pulse  small  and  frequent ; 
skin  not  hot.  The  tympanitic  state  of  the  abdomen,  the  total  absence  of  alvine 
evacuations,  and  the  vomiting,  seemed  to  M.  Lerminier  to  indicate  the  existence 
of  internal  strangulation,  or  at  least  of  some  obstacle  to  the  passage  of  the  food 
towards  the  termination  of  the  large  intestine.  The  abdomen  was  covered  with 
emollient  fomentations,  and  with  embrocations  of  camphorated  oil  of  camomile  ; 
a draught  of  oil  of  sweet  almonds  was  given;  a lavement  of  three  ounces  of 
castor  oil,  and  warm  baths.  In  the  course  of  the  day  the  draught  and  ptisan 
were  vomited  ; the  lavements  were  expelled  as  soon  as  given  : no  stool.  The 
three  following  days  these  symptoms  still  continued  ; the  tympanitic  state  of  the 
abdomen  still  increased  ; the  breathing  was  become  more  difficult.  Purgative 
lavements  of  senna  and  sulphate  of  soda.  On  the  morning  of  the  11th  of  Sep- 
tember the  countenance  was  of  a violet  colour  ; features  changed,  imminent 
suffocation  ; coldness  of  the  extremities  ; pulse  thready ; intellects  perfectly 
clear  ; tongue  natural ; vomiting  of  yellow,  acid  matters  during  a great  part  of 
the  night.  Lavement  consisting  of  an  infusion  of  two  drams  of  tobacco  leaves  ; 
warm  bath.  This  lavement  equally  ineffectual  as  the  former.  In  the  course 
of  the  day  the  dyspnoea  increased  : towards  four  in  the  evening,  just  when  the 
patient  was  leaving  her  bed  in  order  to  go  into  the  bath,  she  expired  suddenly. 

Post-mortem,  17  hours  after  death.  — The  middle  portion  of  the  upper  sur- 
face of  the  left  cerebral  hemisphere  presented  a deep  depression,  which  con- 
tained a rounded  tumour,  about  the  size  of  a nut,  presenting  all  the  characters 
of  the  accidental  fibrous  tissue,  and  developed  between  the  dura  mater  and  the 
arachnoid.  The  cerebral  substance,  forming  the  parietes  of  this  cavity,  was 
healthy.  Nothing  remarkable  in  the  remainder  of  the  encephalon.  The  right 
cavities  of  the  heart  were  distended  by  a dark,  semi-liquid  blood.  The  lungs 
were  engorged,  and  of  a brownish  colour.  The  capacity  of  the  chest  was  very 
much  diminished  ; the  upper  surface  of  the  diaphragm  was  raised  to  the  level 
of  the  fourth  rib  ; no  gas  escaped  into  the  peritoneal  cavity.  The  large  intes- 
tine was  enormously  distended  ; it  concealed  almost  all  the  rest  of  the  viscera; 
one  would  have  said  it  was  the  large  intestine  of  a horse.  This  prodigious  dila- 
tation was  continued  as  far  as  the  sigmoid  flexure  of  the  colon  ; there  the  intes- 
tine became  suddenly  contracted,  and  retained  a small  calibre  as  far  as  the  anus. 
The  little  finger,  when  introduced  into  the^ place  where  the  contraction  com- 
menced, passed  it  with  difficulty;  two  inches  lower  the  intestine  resumed  its 
ordinary  size.  It  was  soon  ascertained  that  this  obstacle  to  the  free  passage  of 
the  finger  was  owing  to  the  presence  of  a fungous  tumour,  which  went  round 
the  intestine  like  a ring;  its  edges  were*  raised  like  those  of  some  species  of 
mushroom  ; the  cerebriform  degeneration  of  the  mucous  membrane  and  of  the 
cellular  tissue  subjacent  to  it,  had  given  rise  to  it.  Below  it  the  intestine  was 
white  and  empty.  Above  it  contained  a great  quantity  of  gas,  and  of  liquid 
greenish  matter.  The  mucous  membrane  was  slightly  injected  through  the 
entire  extent  of  the  large  intestine.  We  were  not  a little  astonished  to  find  on 
the  posterior  surface  of  the  stomach,  nearly  at  an  equal  distance  from  the  cardia 
and  pylorus,  a second  cancer,  entirely  similar  to  that  of  the  intestine.  It  was  a 
little  broader  than  a five-franc  piece.  The  mucous  membrane  of  the  remainder 
of  the  stomach  was  healthy.  Five  or  six  small  rounded  bodies,  each  the  size 
of  a filbert,  and  of  a stony  consistence,  formed  so  many  appendages  around  the 
body  of  the. uterus,  to  which  they  held  by  acellular  prolongation. 


260 


ANDRAL’S  MEDICAL  CLINIC. 


The  tympanitic  state  of  the  abdomen,  and  more  or  less  obstinate  constipation, 
are  no  doubt  rare  phenomena  in  persons  whose  colon  or  rectum  are  cancerous. 
They  existed  for  a long  time  in  this  patient.  But  it  is,  I think,  extremely  rare 
to  see  these  symptoms  suddenly  become  so  severe  as  to  similate  with  ihose  of 
strangulated  hernia.  They  can  only  be  accounted  for  by  admitting  that  the 
tumour,  after  having  for  a long  time  made  imperceptible  progress,  suddenly 
assumed  a sort  of  acute  course  in  its  development ; all  the  phenomena  observed 
in  our  patient  may  thus  be  perfectly  accounted  for.  Death  was  the  result  of 
the  constantly  increasing  difficulty  of  breathing.  When  we  consider  how  little 
air  the  lungs  could  still  receive  towards  the  termination  of  life,  we  shall  not 
feel  surprised  that  a slight  movement,  by  accelerating  the  circulation,  was  suffi- 
cient to  complete  the  asphyxia.  The  increased  quantity  of  blood  which  flowed 
to  the  lung  at  this  moment  being  no  longer  proportioned  to  the  quantity  of  air 
which  might  act  on  it,  sudden  asphyxia  must  be  the  result  of  this  disproportion. 
The  more  acute  pain  which  the  patient  referred  to  the  right  flank  seemed  to  indicate 
that  there  also  the  obstacle  or  strangulation  existed.  If  it  had  been  possible  to 
ascertain  that  the  lesion  was  situated  so  close  to  the  rectum,  one  might  have  tried 
the  introduction  of  a sound  with  advantage.  Let  us  now  direct  our  attention  to. 
the  other  lesions  discovered.  First  we  find  the  instance  of  an  ulcerated  cancer 
of  the  stomach,  the  existence  of  which  was  indicated  only  by  a little  difficulty 
in  digestion,  and  by  frequent  returns  of  anorexia;  the  occult  nature  of  this  cancer 
was  conformable  to  its  state.  How  was  it  that  a tumour  so  large  as  that  seated 
in  the  cerebral  membranes,  and  which  had  made  a considerable  depression  in 
the  brain,  did  not  indicate  its  existence  by  any  marked  symptom  ? We  shall 
probably  find  the  cause  of  this  absence  of  symptoms  both  in  the  slowness  with 
which  the  tumour  was  developed,  and  in  the  portion  of  the  brain  which  was 
compressed  by  it.  A case  similar  to  the  preceding,  with  respect  to  the  lesion 
of  the  intestine,  and  the  symptoms  occasioned  by  it,  has  been  reported  by  Dr. 
Baillie,  in  the  Medical  Transactions,  vol.  i. 

Case  9. — Symptoms  of  typhoid  fever ; all  at  once  signs  of  internal  strangulation,  and  death — 

Twisting  of  the  intestine  around  the  mesentery,  towards  the  commencement  of  the  jejunum — 

Remarkable  dilatation  of  the  duodenum. 

A man,  twenty-seven  years  of  age,  of  a strong  constitution,  frequently  expe- 
rienced abdominal  pains  from  his  earliest  infancy  ; he  often  had  diarrhoea  and 
bilious  vomiting. 

On  the  29th  of  June,  after  having  walked  a great  deal  during  the  day,  and 
having  become  chilled,  he  was  seized  at  night  with  profuse  diarrhoea,  which 
continued  on  the  following  days.  On  the  6th  of  July  he  felt  unusually  hot, 
and  perspired  in  the  evening,  which  symptoms,  as  also  the  diarrhoea,  con- 
tinued till  the  9th  of  July ; he  then  entered  the  Charite,  and  presented  the  fol- 
lowing state  : 

Air  of  stupor,  sub-orbital  pain,  face  pale,  eyes  heavy,  tongue  covered  with  a 
whitish  thick  coat ; thirst,  anorexia,  bad  taste  in  the  mouth ; ten  stools  within 
the  last  twenty-four  hours,  like  water  coloured  yellow  ; abdomen  soft  and  free 
from  pain,  pulse  moderately  frequent  (barley  ptisan,  with  tartaric  syrup,  linseed 
lavement).  On  the  three  following  days  the  prostration  went  on  increasing; 
the  pulse,  which  was  scarcely  frequent  in  the  morning  and  during  the  day, 
became  a little  accelerated  in  the  evening;  at  the  same  time  the  temperature  of 
the  skin  was  raised ; the  purging  neither  diminished  nor  increased.  (Same 
prescription.) 

On  the  13th  the  tongue  became  dry,  the  frequency  of  the  pulse  increased, 
numerous  spots  of  a pale  rose  colour,  of  the  breadth  of  a lentil,  slightly  pro- 
jecting above  the  skin,  sensible  only  to  the  touch,  appeared  on  the  anterior  part 
of  the  chest. 


DISEASES  OF  THE  ABDOMEN. 


261 


On  the  14th  they  extended  to  the  abdomen.  The  purging  was  considerably 
diminished  (three  stools).  There  was  almost  complete  apyrexia ; but  the 
tongue  retained  its  dryness  ; the  teeth  began  to  be  encrusted  ; the  prostration 
was  increased  ; the  skin  of  the  face  assumed  that  earthy  tint  which  accompanies 
and  characterises  the  adynamic  state.  (Blisters  to  the  legs.) 

15th  and  16th.  Same  state  (demulcent  ptisan,  emollient  lavements).  17th. 
Delirium  in  the  night.  The  blisters  on  the  legs  were  dry  ; a new  one  was- 
placed  on  one  thigh. 

18th.  There  was  still  delirium  in  the  evening.  On  the  morning  of  the  19th 
we  found  the  patient  better  than  on  the  preceding  days.  The  tongue  was  moist 
and  looked  well.  Only  two  stools  had  been  passed  since  the  last  twenty-four 
hours.  His  intellects  were  clear.  His  strength  seemed  to  rally  ; temperature 
of  the  skin  was  natural ; pulse  but  65.  We  had  scarcely  left  the  patient  in  this 
improved  state,  when  he  was  seized  all  at  once  with  a pain  in  the  abdomen,  so 
severe  as  to  make  him  scream  ; he  referred  the  seat  of  it  principally  to  the 
parts  around  the  umbilicus ; pressure  neither  increased  nor  relieved  it.  This 
pain  lasted  for  an  hour,  when  we  saw  him  again.  The  features  were  very  much 
altered,  and  indicated  the  greatest  anxiety  ; still  the  pulse  was  not  accelerated. 
A half  an  hour  after,  towards  ten  o’clock,  the  pain  still  continued,  when  the 
patient  vomited  spontaneously  about  a pint  of  bilious  matter  ; he  was  instantly 
relieved.  Towards  noon  the  abdominal  pain  was  again  renewed,  with  great 
violence.  At  four  o’clock  a second  vomiting  took  place,  similar  to  the  first 
with  respect  to  the  nature  and  quantity  of  the  liquid  ; the  pain  disappeared  as 
after  the  former  vomiting.  In  the  evening  we  found  the  patient  calm  and  tran- 
quil, and  entirely  free  from  fever.  He  had  been  three  times  at  stool  since 
morning;  in  the  night  he  had  a little  delirium. 

On  the  morning  of  the  20th  he  suffered  no  pain,  but  his  spirits  were  very 
much  cast  down  ; stupor  very  great ; the  spots  were  effaced,  they  were  pale, 
less  numerous,  and  no  longer  projected  above  the  skin.  Tongue  red  at  the 
apex,  and  clammy  ; pulse  still  slow  and  skin  cool.  (Infusion  of  quinquina, 
with  tartaric  syrup.  Gum  potion,  with  half  an  ounce  of  extract  of  quinquina; 
a little  wine.  Aromatic  fomentations  to  the  abdomen  ; linseed  lavement ; rice- 
water  for  drink.)  At  two  o’clock  in  the  afternoon  the  abdominal  pain  re- 
appeared ; at  six  o’clock  he  vomited  a great  quantity  of  green  bile ; he  felt  re- 
lieved. At  eight  at  night  the  pain  reappeared,  but  was  more  moderate  ; the 
skin  was  moist  and  cold  ; the  pulse,  which  was  very  small,  had  become  fre- 
quent. At  nine  o’clock,  though  the  temperature  of  the  skin  was  not  raised,  he 
complained  of  feeling  an  intolerable  heat  in  every  part  of  him  ; he  threw  off 
the  bed  clothes.  Since  morning  he  had  had  but  one  stool  after  the  lavement; 
at  night  he  was  not  delirious. 

On  the  21st  the  belly  was  generally  painful  on  pressure,  particularly  a little 
above  the  umbilicus  ; the  pulse  was  very  small  and  scarcely  60.  A few  pale 
spots  were  scattered  over  the  abdomen.  Suddenly  an  acute  pain  came  on,  which 
lasted,  however,  for  only  a few  minutes.  At  eight  o’clock  the  pain  again  in- 
creased ; it  ceased,  or,  at  least,  was  very  much  diminished,  after  a copious 
vomiting  of  green  bile  ; two  pints,  at  the  very  least,  were  expelled  from  the 
stomach  at  once.  The  quinquina  was  stopped.  (Tamarind  whey,  barley 
ptisan,  emollient  lavement,  aromatic  fomentations,  two  blisters  to  the  legs.) 

During  the  day  the  pain  and  vomiting  were  several  times  renewed.  In  the 
night  he  became  delirious..  On  the  morning  of  the  22d  his  voice  was  quite 
gone,  he  was  extremely  weak,  his  countenance  was  pale  and  cadaverous.  The 
tongue  was  moist  and  coloured  with  bile.  The  abdomen  was  not  tense.  We 
touched  it  without  at  first  occasioning  any  pain  ; but  on  further  pressure  an 
acute  pain  was  instantly  felt.  The  nose,  hands,  and  feet  were  cold.  H© 


262 


ANDRAL’S  MEDICAL  CLINIC. 


vomited  several  times  during  the  day ; he  had  two  stools.  (Blister  over  the 
epigastrium,  seltzer  water,  anti-emetic  potion  of  Riviere.) 

On  the  23d  the  surface  of  the  entire  skin  was  cold.  He  vomited  frequently. 
On  the  24th  the  pulse  was  thready  and  scarcely  perceptible.  His  skin  was  now 
deadly  cold,  still  his  intellects  were  quite  clear;  he  was  still  strong  enough  to 
raise  himself  up  on  his  elbow.  On  the  evening  of  the  preceding  day  he  got  out 
of  bed  to  go  to  stool ; he  felt  no  abdominal  pain  for  the  last  twelve  or  fifteen 
hours.  He  had  some  hiccup  during  the  night.  He  died  in  the  evening. 

Post-mortem,  48  hours  after  death.  — The  external  surface  of  the  body  was 
scarcely  colder  than  during  the  last  twenty-four  hours  before  death.  A little 
limpid  serum  was  found  in  the  lower  part  of  the  lateral  ventricles.  The  heart 
and  lungs  presented  nothing  remarkable. 

Abdomen.  — The  stomach,  which  was  distended  with  a great  quantity  of  green 
bile,  touched  the  umbilicus  with  its  great  curvature  ; the  mucous  membrane, 
which  was  of  a grey  slate  colour  in  the  splenic  portion,  and  of  a rose  tint  in  the 
pyloric  portion,  was  rather  soft  in  every  part ; but  had  it  not  been  subjected  to 
a sort  of  maceration  by  the  great  quantity  of  liquid  which  was  in  contact  with 
it  for  more  than  forty  hours  ? The  duodenum  had  become  so  much  enlarged, 
that  it  readily  admitted  the  thumb  into  it.  Thejejunum,  at  its  origin,  was  rolled 
on  itself  several  times,  and  was  embraced  by  the  mesentery,  which  pressed  it 
strongly  like  a cord,  whilst  it,  in  its  turn,  likewise  compressed  the  mesentery  : 
the  latter  was  rolled,  like  the  intestine,  several  times  on  itself  from  right  to  left ; 
on  turning  it  three  times  from  left  to  right,  the  mutual  strangulation  of  this  mem- 
brane and  of  the  intestines  was  removed. 

The  superior  mesenteric  artery  and  vein  resembled  a very  tense  cord  from 
which  the  strangulated  parts  seemed  as  it  were  suspended  ; lower  down  these 
vessels  were,  as  it  were,  included  in  the  strangulation  ; all  the  rest  of  the  small 
intestine  also,  nourished  by  these  vessels,  presented  a very  deep  brown  colour, 
arising  from  the  mechanical  stagnation  of  the  venous  blood  in  its  parietes  ; the 
latter  still  retained  their  ordinary  consistence  : the  parietes  of  the  large  intestine 
were  white.  Beneath  the  strangulated  parts  a tumour  existed  about  the  size  of 
an  ostrich’s  egg,  of  a brownish  red  colour,  formed  by  some  lymphatic  glands  and 
sub-peritoneal  cellular  tissue  considerably  engorged.  The  mucous  membrane  of 
the  small  intestine,  which  was  of  black  jet  colour,  presented  an  immense  number 
of  miliary  granulations  ; some  were  also  found,  but  in  less  number,  on  the  mu- 
cous membrane  of  the  large  intestine.  The  liver,  which  was  of  the  ordinary  size, 
was  readily  torn  ; the  gall-bladder  contained  a small  quantity  of  yellow  bile. 
Nothing  remarkable  in  the  other  viscera. 

When  the  patient  who  forms  the  subject  of  the  preceding  case  entered  the 
Charite,  he  presented  nothing  but  the  ordinary  symptoms  of  continued  fever  ; but, 
what  was  very  remarkable,  whilst  the  prostration,  stupor,  dryness  of  the  tongue, 
the  delirium  which  returned  every  night,  and  the  typhoid  eruption  indicated  a 
severe  disease,  the  circulation  remained  in  its  natural  state*  except  that  two  or 
three  times  we  found  the  pulse  a little  frequent  and  the  skin  a little  hot.  The 
ancients  had  noticed  this  rare  pulse  in  malignant  fevers,  and  they  considered  it 
as  a most  unfavourable  symptom.* 

However,  most  of  the  bad  symptoms  had  disappeared,  and  a favourable  pro- 
gnosis might  be  formed,  when  the  symptoms  of  intestinal  strangulation  appeared. 
We  have  carefully  noted,  in  the  progress  of  the  case,  the  extraordinary  inter- 
missions of  the  abdominal  pains,  and  their  diminution  after  each  fit  of  vomiting. 
We  have  remarked  the  almost  cadaveric  coldness  of  the  entire  cutaneous  surface 
for  more  than  twenty-four  hours  before  death,  at  a period  when  the  patient  was 


* See  ante.. 


DISEASES  OF  THE  ABDOMEN. 


263 


still  strong  enough  to  raise  himself  up  and  leave  his  bed.  The  circumstance  of  the 
abdomen  still  remaining  soft,  the  character  of  the  pain  which  was  not  increased 
by  pressure,  distinguished  the  symptoms  of  this  strangulation  from  those  of  a 
peritonitis. 

We  shall  not  attempt  to  account  for  the  mode  in  which  those  strange  and 
almost  inextricable  knots  of  the  small  intestine  around  the  mesentery  occasion- 
ing their  mutual  compression  could  have  been  formed  ; we  can  scarcely  account 
satisfactorily  for  simple  intestinal  intus-susceptions  ; but  we  may  ask  whether 
the  patient  did  not  carry  about  him  an  almost  congenital  predisposition  to  the 
strangulation  of  which  he  died  ? Thence  probably  the  frequent  abdominal 
pains,  and  the  vomiting  to  which  he  was  subject  from  his  infancy.  Is  it  not  to 
the  presence  of  a partial  obstacle  to  the  passage  of  its  contents,  which  must  have 
existed  for  a considerable  time  back,  that  the  enormous  size  of  the  duodenum 
was  owing?  Could  this  intestine  have  acquired  such  enormous  dimensions  in 
a few  days  ? This  we  deem  so  much  the  less  probable,  as  its  valves  were  not 
even  effaced.  The  bile  collected  in  it,  as  in  a great  reservoir,  and  then  passed 
into  the  stomach,  from  which  it  was  expelled  by  vomiting. 


ARTICLE  II. 

“SYMPTOMS  OF  CHRONIC  GASTRITIS. 

These  symptoms  are  of  three  kinds  : some  are  merely  local,  and  consist  in  a 
greater  or  less  disturbance  of  the  functions  of  the  stomach  ; others  arise  from 
the  alteration  of  the  general  progress  of  nutrition,  an  alteration  which  is  the 
necessary  consequence  of  the  gastric  affection  ; others  again  are  purely  sympa- 
thetic. 

Here  an  important  question  presents  itself : are  the  extremely  varied  lesions 
which  we  have  described  in  the  two  preceding  articles,  each  indicated  by  special 
symptoms  ? We  have  no  hesitation  in  answering  in  the  negative  ? With  the 
exception  of  some  circumstances,  which  are  the  mechanical  result  of  the  oblitera- 
tion of  the  cardiaor  pylorus  by  a tumour,  the  same  phenomena  most  commonly 
indicate  during  life  these  organic  alterations  of  form  and  structure  which  differ 
so  much  from  one  another. 

Thus,  for  instance,  it  is  a great  mistake  to  suppose,  that  what  are  called  lanci- 
nating pains  accompany  more  particularly  the  lesion  usually  designated  cancer 
of  the  stomach.  On  the  other  hand,  we  think  that  we  may  infer  from  a 
considerable  number  of  cases,  that  such  pains  are  but  very  seldom  the  result  of 
this  affection.  Then  the  existence  of  lancinating  pains  is  one  of  the  circum- 
stances which  we  took  care  to  point  out  in  the  person  who  forms  the  subject  of 
the  fourth  case.  It  appears  to  us  very  probable  that  the  writers  who  have  given 
these  pains  as  a characteristic  sign  of  cancer  of  the  stomach,  admitted  them  only 
by  analogy  with  that  which  they  observed  in  cancer  of  the  mamma.  Among 
the  persons  in  whom  we  detected,  after  death,  the  existence  of  the  different 
forms  of  gastric  cancer,  whether  scirrhous  or  encephaloid  induration  of  the  tissues 
subjacent  to  the  mucous  membrane,  or  fungous  vegetations  of  this  membrane,  or 
ulcerations  with  destruction  of  the  tissues,  the  bottom  of  the  ulcer  being  formed 
by  the  liver  or  pancreas  ; of  these,  I say,  some  had  never  complained  of  pain  in 
the  epigastrium  ; in  others  it  was  merely  a sensation  of  con  triction  or  habitual 
weight  towards  this  region  ; at  other  times  it  was  produced  only  by  pressure  : 
whilst  at  other  times  the  epigastrium  might  be  pressed  with  impunity.  In 
several  instances  the  pain  was  felt  only  when  food  was  taken  into  the  stomach. 

If  now  we  compare  the  patients  labouring  under  what  are  called  cancerous 


264 


AX  DUAL’S  MEDICAL  CLINIC. 


affections  of  the  stomach  with  those  who  had  only  what  is  recognised  as  a chronic 
gastritis,  we  shall  not  find  either  in  the  character  or  intensity  of  the  pain  any  sign 
by  the  help  of  which  we  could  distinguish  with  certainty  the  latter  disease  from 
the  former. 

Shall  we  seek  more  certain  distinguishing  signs  in  the  varied  disturbances  of 
digestion?  We  shall  not  find  any  thing  more  satisfactory.  Thus,  to  cite  the  two 
extreme  cases,  we  have  seen  persons  who,  during  life,  had  no  other  sign  of  gas- 
tric disease  except  anorexia,  and  at  most  a little  constriction  or  uneasiness  in  the 
epigastrium  after  they  had  eaten,  and  in  whom  we  found  immense  cancerous 
ulceration  in  the  interior  of  the  stomach,  or  else  extensive  scirrhous  induration 
of  its  parietes.  On  the  contrary,  we  have  seen  other  individuals,  who  experi- 
enced a much  more  painful  sensation  in  the  epigastrium  after  eating,  who  vomited 
either  sour  fluid  in  the  morning  and  at  different  periods  of  the  day,  or  their  food, 
who  had  frequent  acid  eructations,  and  yet,  in  these,  what  did  we  find  ? Nothing 
but  red,  brown,  slate-coloured  thickening  of  the  mucous  membrane,  or  else  greater 
or  less  softening  of  this  membrane. 

Will  the  nature  of  the  vomiting  throw  more  light  on  the  matter  ? It  has  been 
said  that  hematemesis  were  exclusively  connected  with  the  existence  of  fungous 
vegetations,  of  cancerous  ulcers,  of  softened  encephaloid  masses  developed 
within  the  stomach.  It  has  been  said  that  these  same  lesions  also  produced 
that  vomiting  resembling  soot  or  coffee-grounds,  which  is  observed  rather  fre- 
quently, and  in  considerable  quantity,  in  persons  labouring  under  a chronic 
affection  of  the  stomach.  No  doubt  such  vomiting  occurs  frequently  when  the 
stomach  is  the  seat  of  one  of  those  lesions  just  mentioned  ; but  it  may  also  pre- 
sent itself  with  very  different  morbid  changes,  and  thence  it  no  longer  possesses 
any  value  to  characterise  any  of  them.  We  have  accordingly  ascertained  its 
existence;  1st,  in  patients  whose  stomach  presented,  in  its  mucous  membrane, 
no  other  change  than  slight  injection  or  softening,  with  greater  or  less  schir- 
vhous  induration  of  the  subjacent  tissues  ; 2dly,  in  others,  whose  gastric  mucous 
membrane  was  hypertrophied  with  grey  or  brownish  colouring,  the  subjacent 
tissues  being  intact. 

With  respect  to  the  general  symptoms,  whether  those  that  are  sympathetic, 
or  those  that  result  from  the  disturbance  or  total  abolition  of  the  process  of 
chymification,  they  do  not  appear  better  adapted  than  the  local  symptoms  to 
distinguish  with  certainty  the  different  organic  alterations  of  the  stomach  from 
-one  another.  It  must,  however,  be  admitted,  that  the  pale  yellow  tint  of  coun- 
tenance, emaciation,  and  wasting  away,  are  particularly  marked  in  the  case 
where  the  stomach  is  the  seat  of  a scirrhous  or  cancerous  affection  properly  so 
called. 

From  these  observations  it  follows  that,  with  the  exception  of  the  case  where 
a tumour  is  felt  through  the  abdominal  parietes,  there  exists  no  certain  sign  to 
distinguish  what  is  called,  inordinary  medical  language,  a cancer  of  the  stomach 
from  that,  which  is  called  chronic  gastritis. 

Thus  with  respect  to  their  symptoms  as  well  as  their  anatomical  characters, 
the  different  forms  of  chronic  gastritis  have  a constant  tendency  to  become  con- 
founded. 

All  this  being  laid  down,  let  us  direct  out  attention  to  some  of  the  symptoms 
which  accompany  chronic  inflammation  of  the  stomach,  and  which  indicate  its 
existence  with  more  or  less  certainty. 

The  tongue,  in  this  affection,  is  far  from  presenting  always  the  same  appear- 
ance. First,  there  is  a certain  number  of  cases,  in  which  it  does  not  at  all  de- 
viate from  its  normal  state  ; and,  what  is  remarkable,  this  happens  precisely  in 
those  cases  where  the  stomach  has  become  the  seat  of  the  most  serious  organic 
alterations. 


DISEASES  OF  THE  ABDOMEN. 


265 


It  is  principally,  in  fact,  in  the  cases  of  cancerous  degeneration  of  the  sto- 
mach, that  we  have  had  an  opportunity  of  observing  this  continuance  of  the 
tongue  in  its  normal  state  ; it  is  often,  in  such  cases,  remarkably  pale. 

With  the  exception  of  this  case,  it  very  seldom  happens  that  in  chronic  gas- 
tritis the  tongue  is  not  more  or  less  changed. 

It  very  seldom  happens  that  it  presents  through  its  entire  extent  that  bright 
redness  with  smooth  appearance  of  its  surface  which  we  have  above  seen  fre- 
quently coincide  with  acute  gastritis.  We  have,  however,  observed  some  per- 
sons who,  for- several  months  in  succession,  presented  such  a state  of  the 
tongue  ; they  had  all  the  other  signs  characteristic  of  chronic  gastritis.  But 
this  appearance  of  the  tongue  alone  should  not  suffice  to  cause  us  to  admit  its 
existence:  from  time  to  lime  persons  are  met  with  who,  without  experiencing 
any  disturbance  in  their  digestive  functions,  have,  like  the  preceding,  a red  and 
smooth  tongue.  The  upper  surface  of  this  organ  is  at  the  same  time  acutely 
sensible.  They  at  first  experienced  pain  in  the  tongue  ; then  the  epithelium 
covering  it  became  detached,  and  the  tongue  then  assumed  that  red  and  smooth 
appearance,  and  retained  it  for  a very  long  time.  This  is  simply  superficial 
glossitis,  which  may  exist  without  any  complication  of  gastritis.  The  acute 
sensibility  now  noticed  does  not  ordinarily  take  place  when  the  redness  of  the 
tongue  is  connected  with  irritation  of  the  stomach. 

It  is  very  common  to  find  in  persons  affected  with  chronic  gastritis,  the 
tongue  covered  with  a thick  coat,  either  white  or  yellow,  sometimes  confined 
to  its  centre,  sometimes  extending  over  all  its  surface.  At  times  nothing  else 
is  observed  but  this  coat,  and  then  the  appearance  of  the  tongue  is  similar  to 
that  which  it  presents  in  cases  where  the  affection  of  the  stomach  is  no  longer  a 
gastritis,  and  yields  to  means  which  would  have  infallibly  exasperated  the  latter 
disease  if  it  had  existed.  But  most  frequently  when  there  is  really  gastritis, 
the  coat  which  covers  the  tongue  is  not  uniform  ; it  is  as  it  were  marked  by  a 
great  number  of  red  points  which  show  what  the  state  of  the  mucous  membrane 
is  beneath  it,  and  which  become  more  prominent  and  more  numerous  towards 
the  apex  of  the  organ. 

There  are  other  persons  likewise  labouring  under  chronic  gastritis,  in  whom 
careless  examination  at  first  detects  nothing  unusual  on  the  upper  surface  of  the 
tongue.  But,  on  viewing  it  more  closely,  we  find  that  towards  its  apex  it  is 
roughened  by  a great  number  of  small  red  granulations,  which  appear  to  be  so 
many  papillae  more  developed  and  more  injected  than  in  their  natural  state. 
These  granulations  do  not  always  remain  in  the  same  state  : at  times  they  are 
very  prominent,  very  red,  and  very  numerous  : at  other  times  they  are  less 
apparent,  paler,  and  fewer  in  number.  Their  development  is  always  in  the 
direct  ratio  of  the  intensity  of  the  gastric  irritation.  Among  the  persons  who 
present  this  particular  state  of  the  tongue,  some  have  a stomach  habitually  sick  ; 
others  have  rather  what  is  called  a delicate  or  irritable  stomach  ; they  are  forced 
to  confine  themselves  to  a certain  regimen  ; they  cannot,  without  great  incon- 
venience, allow  themselves  the  least  excess  in  eating  or  drinking.  This  state  of 
the  tongue  appeared  to  us  more  common  in  the  gastric  irritations  of  young  per- 
sons than  in  those  of  persons  more  advanced  in  life.  It  is  often  observed  in 
young  females  with  a pale  complexion  and  a weak  constitution,  whose  stomach 
is  habitually  deranged  ; its  existence  may  prevent  one  from  considering  and 
treating  as  nervous  the  symptoms  they  present  on  the  part  of  the  digestive 
organs.  We  have  known  several  families,  all  the  children  of  which  presented 
this  unusual  development  of  the  papillae  towards  the  apex  of  the  tongue;  in  all 
these  there  were  at  the  same  time  other  signs  of  gastric  irritation.  In  one  of 
these  families  the  mother  and  her  four  daughters  presented  this  particular  ap- 
pearance of  the  tongue,  and  all  five  had  a very  delicate  stomach. 

It  is  almost  only  in  acute  gastritis  that  the  tongue  becomes  remarkably  dry ; 
23 


266 


ANDllAL’S  MEDICAL  CLINIC. 


in  some  cases,  however,  of  chronic  gastritis  it  no  longer  retains  its  natural  moist 
state  ; it  is  clammy,  and  even  in  the  cases  where  it  is  moist  during  the  day, 
it  is  not  uncommon  to  find  it  dry  on  awaking  ; patients  express  this  by  saying 
that  in  the  morning  their  tongue  is  like  a file;  sometimes  this  state  is  habitual 
to  them,  sometimes  it  appears  only  when  their  state  of  gastric  irritation  becomes 
exasperated. 

There  are  times  when  the  chronic  gastritis  becomes  more  acute  ; then  the 
tongue  assumes  a redder  tint,  or  else  it  is  covered  with  a thick  white  coat  stud- 
ded with  a great  number  of  red  points.  Sometimes  again,  more  particularly 
when  the  system  is  already  very  much  debilitated  by  the  slow  progress  of  the 
chronic  affection,  we  perceive  a diphtherite  supervene  which  attacks  the  tongue 
and  all  the  inside  of  the  mouth.  Though,  in  a great  majority  of  eases,  this 
complication  portends  a rapidly  fatal  termination,  we  have,  however,  sometimes 
seen  the  tongue  and  mouth  gradually  throw  off  the  coat  with  which  they  were 
covered,  and  the  gastric  irritation,  becoming  less  acute,  resume  its  original 
course. 

The  sympathetic  connexions  between  the  mouth  and  stomach  occasionally 
manifest  themselves  by  other  phenomena.  Thus,  in  a considerable  number  of 
persons  who  suffer  habitually  from  the  stomach,  each  exasperation  of  the  gas- 
tric irritation  is  constantly  indicated  by  an  eruption  of  aphthae.  In  others,  the 
salivary  glands  become  painful  and  swollen,  and  profuse  salivation  sets  in. 
This  symptom  is  seldom  permanent,  and  most  frequently  it  assumes  an  inter- 
mittent form,  every  time  the  gastric  irritation  becomes  more  intense. 

The  sensation  of  thirst  and  that  of  hunger  presents  numerous  modifications 
in  chronic  gastritis. 

Thirst  is  often  absent.  In  others  it  becomes  severe  only  at  intervals,  when 
the  inflammation  of  the  stomach  passes  to  a more  acute  state.  Other  indi- 
viduals, on  the  contrary,  are  habitually  distressed  by  thirst,  which  obliges  them 
to  drink  frequently  between  meals.  This  habitual  thirst  is  usually  connected 
with  a somewhat  intense  degree  of  gastric  irritation.  We  know  a lady,  who  is 
about  forty-four  years  of  age,  who  has  been  labouring  under  chronic  irritation 
of  the  stomach  for  more  than  twenty  years,  and  has  not  passed  a single  day 
since  that  time  without  being  tormented  by  a degree  of  thirst,  which  proves  the 
most  painful  part  of  her  disease. 

In  some  this  sensation  of  thirst  is  so  severe,  that  they  every  day  swallow  a 
prodigious  quantity  of  drink.  This  great  thirst  brings  with  it  a very  abundant 
flow  of  urine,  a secondary  diabetes,  which  is  cured  by  removing  the  morbid 
state  of  the  stomach,  which  is  the  real  cause  of  it. 

The  appetite  remains  good  in  several  cases  of  chronic  gastritis,  and  patients 
frequently  have  need  of  the  utmost  determination  to  resist  the  very  keen  desire 
which  forces  them  to  continue  to  eat  when  once  they  have  commenced  a meal. 
The  desire,  however,  like  many  others,  is  very  fallacious,  and  experience  has 
proved  how  injurious  it  is  to  comply  with  it. 

Other  patients  also,  like  the  preceding,  experience  a sensation  which  they 
take  to  be  hunger;  according  to  the  expression  which  many  of  them  use,  they 
feel  a craving,  they  commence  eating  with  real  greediness  ; but  scarcely  have 
they  taken  the  smallest  portion  of  food,  when  they  are  obliged  to  stop,  they 
become  disgusted;  several  say  that  they  feel  their  stomach  so  filled  that,  though 
they  still  have  a craving,  they  can  no  longer  swallow.  Others  fancy  that  the 
food  which  they  intend  should  pass  into  the  stomach  stops  in  the  gullet,  and 
chokes  them.  Thus  different  sensations  indicate  that  sort  of  struggle  which  is 
set  up  between  the  preservative  instinct  which  forces  the  individual  to  repair  his 
loss  by  the  assimilation  of  new  materials  of  nutrition,  and  the  stomach  which 
refuses  to  admit  food  which  it  is  unable  to  digest.  Under  such  circumstances, 
many  patients  seek  after  stimulating  food  and  spices  of  all  kinds  ; sometimes 


DISEASES  OF  THE  ABDOMEN. 


267 


they  are  indulged  with  them,  and  it  is  supposed  that  it  is  still  an  instinct  which 
it  is  useful  to  obey  ; but  they  always  pay  dearly  for  such  efforts,  unless  the 
disease  is  on  its  decline. 

In  other  cases  of  chronic  gastritis,  the  necessity  for  reparation  evinces  itself 
by  an  appetite  so  very  great  that,  if  they  are  not  immediately  gratified,  the 
patients  actually  faint  away.  This  feeling  may  return  several  times  a day,  and 
a very  small  portion  of  food  is  in  general  sufficient  to  appease  it.  For  it  is  not 
real  hunger,  and  in  the  majority  of  cases  this  imperious  necessity  for  taking 
aliment  into  the  stomach  is  promptly  changed  into  a disrelish  for  food. 

There  are  persons  labouring  under  chronic  gastritis  in  whom  the  want  of  repa- 
ration is  indicated  by  extraordinary  sympathies.  In  some  there  is  observed  a 
headach,  which  ceases  when  a little  food  is  taken  into  the  stomach.  Others  are 
attacked  with  dyspnoea,  or  else  they  have  a dry  cough,  which  is  appeased  the 
moment  they  have  eaten.  We  know  a person  in  whom  such  a cough  returned 
in  this  way  periodically  some  time  before  each  of  his  meals. 

Every  time  that  chronic  gastritis  comes  to  be  exasperated,  and  evinces  a ten- 
dency to  pass  into  the  acute  state,  the  appetite  is  completely  lost,  if  it  did  exist ; 
and  if  it  were  succeeded  by  one  of  the  phenomena  just  mentioned,  these  pheno- 
mena also  cease,  and  no  other  symptom  is  now  observed,  except  total  and 
absolute  disrelish  for  all  kinds  of  food. 

Chronic  inflammation  of  the  stomach  is  not  necessarily  accompanied  with 
pain  in  the  region  of  the  suffering  organ.  This  pain  may  be  even  entirely 
absent  in  the  most  severe  cases,  in  those  wherein  the  parietes  of  the  stomach 
are  attacked  with  cancerous  degeneration,  with  ulceration  on  its  internal  sur- 
face. We  have  seen  several  cases  of  this  kind,  in  which  the  epigastrium  had 
remained  entirely  free  from  pain  ; we  have  seen  other  cases,  on  the  contrary, 
in  which  we  should  certainly  have  found  but  very  slight  lesion,  and  still  where 
the  epigastrium  was  either  habitually  or  at  intervals  the  seat  of  very  acute  pain. 
Moreover,  the  extreme  acuteness  of  these  pains  appeared  to  us  to  be  much  more 
frequently  the  product  of  neuralgia  of  the  stomach  than  of  real  gastritis. 

The  nature  of  the  pain,  connected  with  chronic  gastritis,  is  far  from  being 
always  the  same.  At  times  very  acute,  and  appearing  only  at  certain  intervals, 
it  manifests  itself  by  a feeling  of  constriction  towards  the  epigastrium,  whence 
it  has  been  designated  by  the  name  of  cramps  of  the  stomach.  We  have  seen 
cases  in  which  this  particular  pain  appeared  at  intervals  more  or  less  remote  in 
persons  labouring  under  well-marked  chronic  gastritis.  We  have  seen  other 
cases  where,  in  the  absence  of  this  pain,  there  was  no  sign  of  any  affection  of 
the  stomach  ; it  might  then  be  considered  as  purely  nervous.  Still  we  should 
add,  that  we  have  observed  persons  who,  after  having  been  for  a long  time  sub- 
ject to  these  cramps  of  the  stomach,  there  being  no  complication  of  any  other 
gastric  symptom,  presented  at  a later  period  all  the  symptoms  of  a chronic 
inflammation  of  the  stomach.  Is  not  this  one  of  those  cases  in  which  a simple 
neuralgia  is  the  first  commencement  of  an  inflammatory  state  ? 

Other  patients  complain  of  nothing  but  a sensation  of  weight  in  the  epigas- 
trium, or  else  a sort  of  swelling,  which  comes  on  principally  after  they  have 
eaten.  Several  complain  of  a kind  of  bar  which  extends  transversely  over  the 
epigastrium  and  the  two  hypochondria;  some  experience  very  troublesome 
pulsations  towards  the  epigastrium. 

The  seat  of  pain  is  very  variable ; sometimes  it  occupies  all  the  region  of 
the  stomach,  and  the  patients  feel  it  as  far  as  the  level  of  the  umbilicus  ; some- 
times it  occupies  a much  more  circumscribed  point,  either  the  parts  around  the 
pylorus,  or  the  great  cul-de-sac,  or  the  cardia.  In  this  latter  case,  the  patients 
feel,  as  it  were,  a fixed  stinging  pain  towards  the  xiphoid  cartilage  ; one  of  these 
patients  told  11s  one  day,  that  he  constantly  felt  as  it  were  a gimlet  entering  at 
the  point.  Others  complain  of  suffering  principally  above  the  xiphoid  carti- 


26S 


ANDRAL’S  MEDICAL  CLINIC. 


Jage,  in  the  space  occupied  by  the  last  piece  of  the  sternum,  and  yet  it  is  not 
there  that  the  real  seat  of  the  disease  lies.  In  such  cases,  is  it  over  the  nervous 
plexus  which  surrounds  the  lower  extremity  of  the  oesophagus  that  the  suffering 
of  the  stomach  is  more  particularly  felt?  The  pain  may  also  extend  all  along 
the  oesophagus,  and  its  course  is  very  clearly  marked  by  the  patients  themselves; 
then  it  is  a kind  of  burning  heat  which  they  experience  all  along  this  tube. 
Sometimes  the  pain  is  felt  towards  the  middle  of  the  back. 

In  one  case,  where  the  pain  had  been  one  of  the  predominant  phenomena  of 
the  disease,  we  found  near  the  pancreas  a morbid  change  which  might  be  con- 
sidered as  its  principal  cause.  It  was  in  a woman,  sixty  years  of  age,  who 
entered  the  Pitie,  complaining  of  a very  acute  pain  towards  the  middle  of  the 
dorsal  region,  which  did  not  allow  her  a moment’s  rest.  This  woman  had  all 
the  symptoms  of  chronic  gastritis.  Some  time  after  her  admission  into  the 
hospital,  another  pain  developed  itself,  the  principal  seat  of  which  was  towards 
the  praecordial  region,  and  radiating  from  thence  to  all  the  left  side  of  the  chest ; 
percussion  detected  a dull  sound  in  the  region  of  the  heart  over  a greater  extent 
than  ordinary,  to  as  far  as  the  lower  part  of  the  sternum.  Auscultation  detected 
nothing  particular;  the  pulse  which  was'frequent  still  retained  its  regularity  ; 
the  breathing  was  not  perceptibly  embarrassed.  About  fifteen  days  passed  on 
in  this  way,  when  the  praecordial  pain  disappeared,  and  that  of  the  back' dimi- 
nished, but  then  symptoms  of  another  kind  supervened  ; the  patient  began  to 
sink  rapidly  ; her  tongue  became  dry  ; a creamy  coat  extended  over  the  tongue 
and  cheeks,  and  death  soon  terminated  this  long  series  of  suffering.  What  we 
found  at  the  post-mortem  examination  was  as  follows  : — A pint  of  fluid  like 
blood  just  drawn  from  a vein  filled  the  cavity  of  the  pericardium  ; thick  false 
membranes  placed  one  over  the  other  covered  all  the  internal  surface  of  this 
fibro-serous  sac.  Thus  this  pain  was  explained,  which,  proceeding  from  the 
praecordial  region,  extended  over  the  left  side  of  the  chest,  with  dulness  of  sound 
at  the  base  of  the  sternum.  The  mucous  membrane  of  the  stomach  was  soft- 
ened over  the  principal  portion  of  its  extent,  and  was  very  much  injected  in 
several  points;  thus  the  symptoms  of  gastritis  were  explained.  But  did  this 
lesion  of  the  stomaeh  account  for  the  dorsal  pain,  which  had  been  so  long  the 
predominant  symptom  ? it  was  at  least  doubtful,  and  this  pain  appeared  to  us 
lather  to  recognise  for  its  cause  the  following  alteration,  which  is  very  re- 
markable for  its  rare  occurrence.  In  the  place  ordinarily  occupied  by  the  pan- 
creas, there  was  found  a tumour  of  a cancerous  nature  (a  mixture  of  the  scir- 
rhous and  encephaloid  tissues),  which  posteriorly  rested  on  the  aorta  and  ver- 
tebral column.  This  tumour  was  as  it  were  embraced  by  the  duodenum,  which 
circumscribed  it  within  its  three  curves  ; within  it  we  observed  here  and  there 
some  debris  of  the  tissue  of  the  pancreas.  Another  tumour  of  the  same  nature, 
about  the  size  of  a hen’s  egg,  appeared  between  the  liver  and  the  diaphragm,  a 
little  to  the  right  of  the  epigastrium.  It  adhered  closely  to  the  liver.  No  lesion 
was  found  in  any  other  part.  It  is  remarkable,  no  doubt,  that  in  an  individual 
labouring  under  gastritis  the  stomach  did  not  undergo  the  cancerous  degenera- 
tion at  the  time  when  the  predisposition  to  this  degeneration  was  demonstrated 
by  the  existence  of  the  two  tumours  just  described.  It  is  also  well  to  note  that, 
in  most  of  the  cases  in  which  the  pancreas  has  been  found  cancerous,  there 
were  cancers  at  the  same  time  in  other  organs  ; here  they  were  not  found  in 
any  organ.  But  let  us  return  to  our  subject. 

Whatever  be  the  seat  and  nature  of  the  epigastric  pain,  it  varies  in  different 
individuals  with  respect  to  the  circumstances  which  exasperate  or  reproduce  it. 

The  process  of  digestion  is  with  many  persons  the  cause  of  the  return  or 
increase  of  the  pain  ; still  several  persons  say  that  they  suffer  whether  they  eat 
or  not,  and  whatever  be  the  nature  of  the  food  which  they  take  ; but  these  are 
rare  cases,  which  appertain  rather  to  other  morbid  states  of  the  stomach,  of 
which  we  shall  speak  presently,  than  to  real  gastritis. 


DISEASES  OF  THE  ABDOMEN. 


269 


In  a considerable  number  of  persons,  the  uneasiness  occasioned  in  the  stomach 
by  the  process  of  digestion  does  not  occur  until  a considerable  time  after  food 
has  been  taken.  Thus  we  meet  persons  who  suffer  in  the  stomach  principally 
in  the  morning  or  on  awaking,  and  in  whom  the  suffering  is  so  much  the 
greater,  according  as  they  have  been  less  reserved  in  their  diet  on  the  preced- 
ing day. 

It  would  be  interesting  to  know  precisely  the  nature  of  the  gases,  which  are 
disengaged  in  such  great  quantity  from  the  stomach  in  a great  number  of  cases 
of  chronic  gastritis.  We  know  that  sometimes  they  are  devoid  of  smell  or 
taste,  and  are  independent  of  the  process  of  digestion,  and  that  sometimes  they 
accompany  this  process  more  particularly  ; they  then  acquire  the  scent  of  sul- 
phuretted hydrogen,  and  their  taste  is  often  extremely  acrid,  so  as  to  occasion 
considerable  pain  in  the  parts  through  which  they  pass. 

Chronic  gastritis,  in  its  numerous  shades,  is  seldom  accompanied  by  vomit- 
ing ; the  latter  symptom  occurs  principally  in  two  cases ; either,  when  under 
the  influence  of  causes  appreciable  or  not,  the  chronic  inflammation  of  the 
stomach  passes  into  a more  acute  form,  or  else  when  the  alteration,  of  which 
the  stomach  is  the  seat,  opposes  an  obstacle  to  the  free  passage  of  the  food, 
eithfer  at  its  entrance  into  the  stomach  or  when  it  is  making  its  exit  from  it.  It 
is  then  principally  in  cases  of  a cancerous  affection  of  the  cardia  or  pylorus 
that  vomiting  takes  place.  In  the  former  case  this  vomiting  occurs  immediately 
after  food  has  been  taken ; in  the  second  case  it  does  not  come  on  till  a much 
later  period.  Some  patients  vomit  every  day,  four  or  five  hours  only  after  they 
have  eaten  ; in  other  cases  the  vomiting  does  not  come  on  till  after  much  longer 
intervals,  every  five,  six,  or  eight  days.  The  persons  in  this  case  often  vomit  at 
once  an  enormous  quantity  of  matter;  in  the  preceding  article  we  have  explained 
how  in  "such  cases  the  stomach  acquires  a prodigious  size,  and  becomes  like  a 
large  bag  for  carrying  food,  as  long  as  it  can  be  distended  ; we  can  then  fre- 
quently trace  this  bag,  both  with  the  eye  and  by  our  touch,  through  the  at- 
tenuated abdominal  parietes,  and  more  frequently  stilt  we  can  ascertain  the 
dilatation  of  the  stomach  by  the  gurgling  noise  readily  produced  in  the  epigas- 
trium, by  shaking  the  patient’s  trunk.  The  same  takes  place  in  patients  who 
themselves  can  produce  this  gurgling  by  forcibly  contracting  the  abdominal 
parietes,  so  that  these  parietes  alternately  are  removed  from  and  brought  in 
contact  with  the  viscera  which  they  cover. 

With  respect  to  those  cancers  of  the  stomach  which  affect  the  body  of  this 
viscus,  they  may  exist  in  all  possible  degrees  without  vomiting  being  ever  pro- 
duced. Then  we  have  often  found  on  one  or  other  surface  of  the  stomach  either 
extensive  ulcerations  surrounded  by  a scirrhous  tissue  or  large  cancerous  vege- 
tations, in  persons  who,  during  the  course  of  their  long  illness,  had  never  had 
either  nausea  or  vomiting. 

The  matters  vomited  by  persons  labouring  under  chronic  gastritis  are  more 
particularly  either  food  or  mucus  secreted  by  the  stomach  itself,  or  bile,  or  blood 
with  its  ordinary  qualities,  or  a black  matter,  which  seems  to  be  nothing  but 
blood  changed  by  its  having  been  in  the  stomach  for  some  time.  (See  the 
preceding  article  on  this  point.) 

The  vomiting  of  mucus  may  be  merely  accidental,  and  connected  with  a 
temporary  increase  of  the  gastric  irritation.  At  other  times  it  is  habitual ; thus 
several  patients  throw  up  every  day,  either  in  the  morning  only,  or  several 
times  in  the  course  of  the  day,  a whitish  viscid  liquid,  very  much  resembling 
albumen  which  has  not  been  subjected  to  boiling.  This  sort  of  vomiting  is  not 
often  accompanied  by  any  other,  and.it  by  no  means  always  occasions  for  in- 
stance that  of  the  food. 

Chronic  gastritis  is  scarcely  ever  accompanied  by  bilious  vomiting,  except 
when  it  becomes  more  acute.  Sometimes  this  sort  of  vomiting  precedes  the 


270 


ANDRAL’S  MEDICAL  CLINIC. 


other  symptoms  ; it  occurs  from  time  to  time,  leaves  no  trace  after  it,  and  it  is 
only  at  a later  period,  and  often  without  its  reappearing,  that  all  the  signs  of 
chronic  gastritis  supervene.  Thus  we  have  seen  a person  who,  from  his  eigh- 
teenth to  his  thirty-seventh  year,  scarcely  passed  a summer  without  being 
attacked  with  copious  vomiting  of  bile,  and  alvine  evacuations  of  the  same 
nature.  He  for  some  days  felt  a sort  of  general  indisposition  and  fatigue,  he 
lost  appetite,  the  epigastrium  became  a little  sensible  to  the  touch,  and  bilious 
evacuations  commenced  ; they  continued  for  two  or  three  days,  and  then  his 
health  was  restored.  In  all  the  other  seasons  of  the  year  this  person  digested 
his  food  well,  and  suffered  nothing  from  his  stomach  ; but  such  did  not  con- 
tinue to  be  the  case  ; towards  the  thirty-sixth  year  of  his  age  his  stomach  began 
to  be  permanently  affected,  and  by  degrees  he  presented  all  the  symptoms  of 
scirrhous  pylorus. 

It  is  generally  supposed  that  vomiting  of  black  matter  like  chocolate,  coffee- 
grounds,  or  soot,  is  one  of  the  least  equivocal  signs  of  cancerous  degeneration 
of  the  stomach.  In  the  preceding  article  we  have  cited  cases  wherein  this 
vomiting  appeared  without  there  being  cancerous  ulceration  of  this  organ,  nor 
even  a trace  of  cancer  in  its  parietes.  But  in  the  cases  which  we  have  cited, 
the  stomach,  without  being  cancerous,  presented  alterations  which  characterise 
others  forms  of  chronic  gastritis.  Here  now  are  other  cases  in  which  the  sto- 
mach was  not  the  seat  of  any  appreciable  lesion,  though  during  life  profuse 
black  vomiting  had  occurred.  In  one  of  these  cases  the  cancerous  masses 
had  attacked  the  liver  ; in  the  others  the  principal  disease  was  chronic  perito- 
nitis. 

1st  Case.  A man,  thirty-five  years  of  age,  entered  the  Maison  Royale  de 
Sante  with  dropsy  (serum  in  the  peritoneum  ; infiltration  of  the  scrotum  and 
lower  extremities;  no  trace  of  oedema  in  the  upper  extremities,  nor  in  the 
face).  After  the  scrotum  was  scarified,  the  skin  of  the  part  became  red,  and  phleg- 
monous erysipelas  attacked  the  thighs,  the  iliac  fossae,  and  ascended  as  far  as  the 
flanks.  Whilst  this  erysipelas  was  becoming  developed,  the  patient  vomited 
a great  quantity  of  black  matter  like  soot  mixed  up  with  water.  He  died  three 
days  after  this  vomiting  appeared. 

We  found  the  stomach  free  from  all  appreciable  lesion.  It  was  pale  on  its  internal 
surface,  and  its  different  membranes  were  of  their  natural  thickness  and  consist- 
ence ; the  remainder  of  the  digestive  tube  was  pale  and  healthy  like  the  stomach. 
The  liver,  which  was  of  a moderate  size,  presented  on  its  interior  twelve  white 
hard  masses,  possessing  all  the  characters  of  encephaloid  matter  in  the  state  of 
crudity.  The  spleen  was  large  and  very  firm.  The  other  organs  presented 
nothing  remarkable.  The  cellular  tissue  of  the  scrotum,  thighs,  and  hips  were 
infiltrated  with  sero-purulent  liquid. 

2d  Case.  A man,  fifty-three  years  of  age,  during  his  stay  in  the  Maison  Royale 
de  Sante,  presented  the  different  symptoms  of  chronic  peritonitis;  still  further, 
he  had  some  cough,  and  in  the  course  of  his  life  had  had  some  attacks  of  he- 
moptysis. He  kept  to  milk  diet.  All  at  once  this  man  was  seized  with  vomit- 
ing of  matter  resembling  coffee-grounds  ; on  the  two  following  days  he  passed 
similar  matter  by  stool.  Rapid  exhaustion  followed  these  evacuations,  and  he 
died. 

On  opening  the  body  we  found  the  intestines  united  into  one  mass  by  false 
membranes  which  were  studded  with  myriads  of  tubercles.  The  internal  sur- 
face of  the  stomach  presented  a very  slight  injection  in  some  points  ; the  gas- 
tric mucous  membrane  was  everywhere  of  its  normal  thickness  and  consistence, 
and  no  alteration  was  observable  in  its  subjacent  tissues.  The  small  intestine 
was  pale  and  healthy.  Such  was  not  the  case  with  the  large  intestine  ; it  was 
filled  throughout  with  a black  matter  similar  to  coffee-grounds  mixed  with 
another  substance  of  a yellowish  grey  colour,  which  crumbled  under  the  finger, 


DISEASES  OF  TIIE  ABDOMEN. 


271 


and  was  fatty  to  the  touch  ; it  resembled  clay  ; the  black  substance  was  more 
abundant  than  the  other  ; the  intestine  was  distended  by  it.  After  the  latter  had 
been  well  washed,  its  inner  surface  was  found  to  be  perfectly  white,  and  its 
different  coats  healthy.  Nothing  remarkable  in  the  liver  or  in  the  bile  contained 
in  the  gall-bladder.  The  spleen  was  small  and  dense.  The  upper  lobe  of  each 
lung  contained  tubercles  ; the  greater  quantity  was  found  in  the  left  lung.  The 
heart,  which  was  remarkably  pale,  without  its  tissue  being  more  friable  than 
usual,  contained  a small  quantity  of  blood  in  its  cavities. 

3d  Case.  A man,  sixty  years  of  age,  entered  the  Maison  Royale  de  Sante 
with  the  signs  of  chronic  peritonitis.  On  the  right  of  the  epigastrium  the  ab- 
dominal parietes  formed  a striking  prominence,  such  as  would  result  from  the 
presence  of  a tumour.  October  2,  this  person  was  attacked  with  diarrhoea  ; he 
then  vomited  a great  quantity  of  greenish  bile  several  times;  he  continued  to 
vomit  bile  on  the  two  following  days.  On  the  5th  the  nature  of  the  vomiting 
was  changed  : it  consisted  of  black  matter  resembling  coffee-grounds  ; from  the 
moment  this  new  vomiting  appeared,  the  features  became  rapidly  changed  ; a 
state  of  great  exhaustion  ensued,  like  that  which  accompanies  profuse  hemor- 
rhage, and  death  took  place  on  the  6th  of  October,  at  four  in  the  morning. 

At  the  post-mortem  examination  we  found  a sero  purulent  effusion  in  the  pe- 
ritoneum, and  falsemembranes  which  united  the  intestines  together  in  every  part. 
Small  miliary  tubercles  were  scattered  over  the  gastro-colic  epiploon,  a profuse 
collection  of  pus  was  found  in  front  of  the  stomach  ; a cavity  was  formed 
bounded  entirely  by  the  abdominal  parietes,  posteriorly  by  the  stomach,  on  the 
left  by  the  spleen,  and  on  the  right  by  the  liver,  which  seemed  to  have  been 
flattened  by  this  collection.  Anteriorly  and  below  the  edge  of  the  liver,  towards 
the  point  occupied  by  the  gall-bladder,  another  pouch  was  found,  the  parietes 
of  which  consisted  of  false  membranes  easily  torn  by  the  finger;  this  pouch 
also  contained  some  pus.  It  was  this  pouch  which  during  life  formed  the  promi- 
nence on  the  abdominal  parietes  towards  the  right  hypochondrium.  False  mem- 
branes placed  one  over  the  other  thickened  the  parietes  of  the  gall-bladder  to  an 
extraordinary  degree. 

The  stomach  was  empty,  its  internal  surface  was  white,  and  its  different 
membranes  in  the  natural  state.  The  duodenum,  jejunum,  ileum,  and  all  the 
large  intestines,  were  filled  with  a black  matter  resembling  coffee-grounds. 
Beneath  this  matter  no  other  morbid  change  was  found  except  a number  of  black 
points  on  the  villi  of  the  duodenum  and  of  the  commencement  of  the  jejunum. 
The  liver  was  remarkably  dense  ; it  presented  a great  number  of  irregular 
patches  of  a whitish  grey  colour,  consisting  of  the  yellow  substance  divested  of 
colour,  the  convolutions  of  which  were,  as  it  were,  heaped  on  one  another,  the 
red  substance  having  disappeared  between  them.  The  spleen,  which  was 
pale,  was  of  the  natural  size  and  consistence.  The  summit  of  both  lungs  pre- 
sented some  tubercles  scattered  through  a hard  and  black  tissue.  The  heart, 
which  was  pale,  contained  a small  quantity  of  liquid  blood,  as  did  also  the 
vessels. 

These  three  cases  prove  clearly  that  the  black  vomiting,  which  is  often  one  of 
the  effects  of  cancerous  degeneration  of  the  stomach,  may  also  result  solely  from 
an  exhalation  of  the  gastric  mucous  membrane,  an  exhalation  not  connected 
with  any  lesion  of  the  stomach  appreciable  on  the  dead  body.  This  exhalation 
may  also  take  place  at  the  same  time  in  the  intestine,  in  which  again  no  lesion 
is  to  be  found.  Only  in  the  case  just  cited  one  might  be  struck  with  the  very 
pale  appearance  of  ail  the  internal  surface  of  the  digestive  tube,  and  with  the 
sudden  sinking  of  the  patient’s  strength,  which  took  place  from  the  first  appear- 
ance of  the  evacuations.  These  are  so  many  phenomena  which  usually  accom- 
pany every  profuse  hemorrhage. 

One  of  the  symptoms  most  usually  accompanying  chronic  gastritis,  when  it 


ANDRAL’S  MEDICAL  CLINIC. 


212 

is  free  from  any  complication  with  the  rest  of  the  intestine,  is  obstinate  consti- 
pation. It  is  increased  or  diminished  according  as  the  gastric  irritation  is  more 
or  less  severe.  In  such  cases  the  patients  too  often  attribute  to  the  constipation 
their  gastric  symptoms,  and  the  purgatives  to  which  they  have  recourse  to  over- 
come it  seldom  fail  to  aggravate  the  complaint;  and  always  after  the  stools 
which  they  thus  provoke  artificially,  they  still  remain  more  constipated  than 
before.  The  only  means  of  subduing  this  constipation,  is  to  diminish  the  gas- 
tric irritation. 

In  chronic  gastritis  the  functional  disturbances  are  not  confined  merely  to  the 
digestive  organs.  The  irritated  stomach  reacts  on  the  different  organic  systems, 
and  from  thence  there  are  produced  symptoms  as  different  as  the  individual  pre- 
dispositions themselves  are. 

On  the  part  of  the  nervous  system  functional  disturbances  the  most  varied  may 
be  observed.  For  instance,  it  is  very  frequent  to  see  in  persons  labouring  under 
chronic  gastritis,  each  digestion  accompanied  by  extreme  debility,  a general 
feeling  of  fatigue,  wandering  pains  in  the  limbs,  a sort  of  distress  which  disap- 
pears according  as  the  digestion  approaches  its  termination.  It  may  happen  that 
whilst  these  general  symptoms  are  observed,  the  suffering  on  the  part  of  the 
stomach  itself  may  be  very  slight;  and  observe  that  it  is  by  these  same  general 
symptoms  that  acute  inflammation  also  of  the  stomach  often  commences,  and 
that  in  this  case  also  it  happens  more  than  once  that  the  general  symptoms  are 
much  more  marked  than  the  local.  With  respect  to  this  circumstance,  see  the 
preceding  part  of  the  work. 

Independently  of  this  effect  which  is  observed  in  a great  number  of  cases, 
there  are  others  more  uncommon,  which  depend  on  the  particular  state  in  which 
the  gastric  affection  may  find  the  nervous  system  in  each  patient.  Thus  in 
some  persons  headachs  are  observed  which  are  evidently  dependent  on  the  gas- 
tric irritation  with  which  they  are  tormented. 

We  know  a lady  who,  labouring  under  chronic  gastritis  for  several  years  back, 
is  seized  with  a well-marked  numbness  of  the  upper  extremity  of  the  right  side 
every  time  the  gastritis  becomes  worse.  We  know  another  who,  having  had 
facial  neuralgia  in  her  youth,  has  ever  since  found  this  neuralgia  to  return  every 
time  that  her  stomach,  which  is  habitually  delicate,  has  become  the  seat  of 
increased  irritation. 

We  have  been  consulted  by  a young  man  affected  like  the  preceding  persons 
with  chronic  gastritis,  whose  entire  skin  becomes  from  time  to  time  so  acutely 
sensible,  that  he  cannot  bear  the  least  contact  without  pain.  He  has  remarked 
that  this  extreme  cutaneous  sensibility  was  constantly  preceded  by  an  increased 
severity  of  the  gastric  symptoms,  and  that  it  invariably  diminished  with  the 
latter. 

We  once  attended  a patient  thirty-six  years  of  age,  who  enjoyed  all  the  com  - 
forts of  life,  who  was  haunted  by  the  idea  of  suicide  during  all  the  time  he  had 
gastritis;  he  had  been  labouring  under  it  for  three  or  four  months  when  he  ap- 
plied to  us.  By  means  of  suitable  treatment  we  removed  the  gastric  inflam- 
mation, and  from  the  moment  his  digestion  was  restored  he  gave  up  all  idea  of 
suicide. 

We  know  that  many  cases  of  hypochondriasis  maybe  referred  primarily  to  a 
morbid  state  of  the  stomach.  How  many  persons  have  we  not  seen  who,  with- 
out becoming  hypochondriacal,  were  seized  with  profound  melancholy,  for  which 
they  could  not  account,  every  time  they  complained  of  their  stomach  ! 

The  circulation  is  but  little  changed  by  chronic  gastritis.  Excepting  the  case 
where  this  affection  passes  for  a time  into  tiie  acute  stage,  the  pulse  remains  free 
from  frequency,  and  the  skin  continues  cool.  In  some  persons,  however,  the 
process  of  digestion  is  accompanied  by  a slight  febrile  paroxysm. 

In  consequence  of  a peculiar  disposition,  several  persons  labouring  under 


DISEASES  OF  THE  ABDOMEN. 


273 


chronic  gastritis  are  annoyed  with  palpitations  evidently  connected  with  this 
gastritis,  and  which  are  observed  to  increase  and  diminish  with  it.  These  pal- 
pitations, which  are  all  sympathetic,  are  chiefly  observed  in  persons  disposed 
to  them  by  the  size  of  their  heart,  and  the  gastric  irritation  then  becomes  the 
occasional  cause  of  the  more  rapid  development  of  the  aneurism,  the  rudiment 
of  which  these  persons  carry  about  them.  Cure  their  gastritis  and  you  will 
often  see  the  affection  of  the  heart  again  become  stationary. 

The  respiratory  apparatus  is  occasionally  affected  by  the  irritation  of  which  the 
stomach  is  the  seat.  Thus,  in  more  than  one  case  of  chronic  gastritis,  one  of  the 
most  prominent  symptoms  accompanying  the  process  of  digestion,  is  a very 
painful  dyspnoea,  the  primary  cause  of  which  many  patients  of  themselves  refer 
to  the  stomach.  Is  it  by  the  influence  of  the  pneumogastric  nerve  that  the  dis- 
turbance of  the  respiration  can  be  accounted  for  in  such  cases? 

At  other  times  it  is  not  this  dyspnoea  that  is  observed,  but  every  exasperation 
of  the  gastritis  is  accompanied  by  a dry  cough,  which  is  purely  sympathetic, 
and  which  has  been  for  a long  time  designated  by  the  name  of  gastric  cough.  Its 
existence  does  not  appear  to  us  to  be  at  all  a matter  of  doubt ; but  still  we  must 
add,  that  this  cough  more  frequently  appears  in  persons  who  labour  under  some 
affection  of  the  lungs,  as  wre  a little  while  ago  remarked,  that  palpitations  produced 
by  chronic  gastritis  were  observed  principally  in  persons  who  labour  under  an 
affection  of  the  heart.  Interrogate  phthisical  patients  on  this  matter  ; the  greater 
part  of  them  will  tell  you  that  every  time  they  have  eaten,  their  cough  becomes  more 
severe,  and  'this  is  chiefly  marked  in  them,  if  their  stomach  begins  to  be  irritated. 

The  different  organs  of  secretion  do  not  remain  exempt  from  the  disturbance 
occasioned  in  the  system  by  gastric  irritation.  The  secretions  of  the  skin  are 
those  most  frequently  modified  ; they  are  diminished  or  suppressed,  and  thence 
results  that  peculiar  dryness  of  this  organ  observable  in  patients  affected  with 
chronic  gastritis.  This  dryness  is  chiefly  remarkable  in  the  palms  of  the  hands. 

Is  there  any  connection  between  this  almost  constant  modification  of  the  cuta- 
neous secretions  and  those  different  eruptions  so  often  observable  on  the  skin 
during  the  course  of  some  cases  of  gastritis  ? We  were  once  consulted  by  a 
young  man  accustomed  to  gastric  affections,  whose  skin  was  covered  with  patches 
of  urticaria  every  time  the  irritation  of  the  stomach  became  increased.  We  have 
seen  another  case  still  more  extraordinary  ; a young  man  had  been  labouring  for 
several  months  underall  thesymptoms  of  gastric  irritation  ;atonetime  he  tookfour 
drachms  of  magnesia ; he  instantly  felt  a most  painful  weight  in  the  epigastrium  ; 
he  had  nausea,  which  was  followed  by  vomiting,  and  presently  his  entire  skin  be- 
came covered  with  large  patches  of  urticaria.  This  eruption  continued  for  thirty 
hours  and  disappeared.  There  was  here  a very  striking  coincidence  between  the 
accidental  exasperation  of  the  gastric  irritation,  and  the  appearance  of  the  cuta- 
neous eruption.  It  is  well  known  that  in  many  cases  herpetic  affections  never 
fail  to  become  more  severe,  every  time  the  stomach  becomes  irritated.  Thence 
the  indispensable  necessity  of  the  mildest  regimen  in  affections  of  this  kind. 

When  gastritis  gives  rise  to  vomiting  essentially  composed  of  bile,  it  must 
be  admitted  that  the  secretion  of  the  liver  itself  is  modified.  For  in  the  ordinary 
state,  the  bile  enters  the  duodenum  only  in  small  quantities  at  a lime,  as  may 
be  observed  in  living  animals.  An  increased  quantity  of  bile  therefore  must 
flow  into  the  intestine  all  at  once,  and  following  a course  contrary  to  its  natural 
course,  it  rises  towards  the  stomach,  and  passes  the  duodenum  ; to  be  sure  it 
might  also  so  happen  that  it  was  only  by  little  and  little  that  the  bile  entered 
the  stomach,  and  that  this  organ  did  not  throw  it  up  until  it  was  collected  there 
in  sufficient  quantity. 

The  urinary  secretion  is  modified  in  a thousand  ways  in  persons  labouring 
under  chronic  gastritis,  but  without  this  modification  being  more  peculiar  to 
gastritis  than  to  any  other  disease  ; we  shall  not  therefore  dwell  on  it  here,  and 


2 74 


ANDllAL’S  MEDICAL  CLINIC. 


we  shall  merely  cite  two  rather  remarkable  cases  which  we  have  met,  which 
prove  how  great  the  influence  of  the  diseased  stomach  may  be  on  the  functions 
of  the  kidneys. 

A man,  about  forty  years  of  age,  presented,  for  a long  time  back,  the  symp- 
toms of  an  habitual  gastric  irritation.  At  three  different  times  he  was  attacked, 
without  any  known  cause,  with  an  acute  pain  in  the  epigastrium,  followed  by 
copious  vomiting  of  bile.  Every  time  these  symptoms  returned  he  passed 
several  gravel  stones  when  voiding  his  urine,  which  consisted  of  uric  acid.  At 
no  other  period  of  his  life  did  he  observe  his  urine  to  contain  any. 

A young  lady  consulted  us  for  diabetes  mellitus,  to  which  she  had  been  sub- 
ject for  the  last  year.  We  put  her  under  an  exclusively  animal  diet,  which  she 
was  not  able  to  continue  long.  We  soon  discovered  that  in  this  individual  the 
diabetes  was  complicated  with  chronic  gastritis,  which  seemed  to  have  been 
completely  neglected  in  the  treatment  hitherto  adopted.  We  ascertained  from 
the  patient,  that  she  began  to  complain  of  her  stomach  and  of  bad  digestion 
some  months  before  the  first  appearance  of  her  diabetes.  We  thought  the  best 
treatment  was  to  endeavour  to  remove  the  gastric  irritation,  and  we  recollected 
some  cases  detailed  by  Dr.  Dezeimeris,  in  which  there  was,  as  in  our  patient, 
a co-existence  of  chronic  gastritis  and  diabetes,  and  in  which  the  latter  disease 
was  removed  by  removing  the  inflammation  of  the  stomach.  Some  leeches 
were  first  applied  to  the  epigastrium  ; this  region  was  then  rubbed  with  tartar 
emetic  ointment,  at  the  same  time  we  confined  the  patient  to  a very  mild  diet : 
we  tried  milk,  which  till  then  had  been  prohibited,  and  as  she  digested  it  very 
well,  it  soon  constituted  her  only  diet.  This  treatment  was  continued  for  three 
months;  at  the  end  of  this  time  there  was  no  longer  any  trace  of  gastric 
irritation,  and,  what  is  very  remarkable,  the  urine  returned  to  its  natural 
state.  Thus,  by  curing  the  gastritis,  we  removed  the  diabetes,  so  that  it  was 
reasonable  to  suppose  that  the  latter  of  these  affections  was  dependent  on  the 
former. 


ARTICLE  111. 

TREATMENT  OF  CHRONIC  GASTRITIS. 

A disease  such  as  chronic  gastritis,  which  presents  such  varied  degrees  of 
intensity,  which  corresponds  with  lesions  so  varied,  and  which  is  indicated  by 
symptoms  oftentimes  so  different,  cannot  require  in  all  cases  the  same  treat- 
ment. There  is  a shade  of  chronic  gastritis,  in  which  the  treatment  must  be  as 
rigorously  antiphlogistic  as  in  acute  gastritis  ; there  is  another  shade  of  this 
affection  in  which  the  treatment  should  be  entirely  different,  and  where  it  is  a 
more  or  less  stimulant  plan  of  treatment  that  has  any  chance  of  success.  This 
occurs  towards  the  termination  of  a certain  number  of  cases  of  chronic  gastritis, 
when  the  inflammation  was  previously  combated  by  suitable  means,  and  when 
it  is  on  the  point  of  being  removed.  In  some  time  it  will  no  longer  exist,  and 
still  the  functions  of  the  stomach  will  be  far  from  having  yet  returned  to  the 
normal  state.  Then  it  frequently  happens  that  we  cannot  restore  them  but  by 
having  recourse  to  a new  mode  of  treatment,  and  principally  by  changing  the 
quality  of  the  food.  Hitherto  the  mildest  diet,  and  medicines  of  a correspond- 
ing nature,  had  been  alone  prescribed,  and  the  disease  had  not  ceased  to  im- 
prove under  their  influence  ; now  it  remains  stationary,  and  presently  it  will 
present  itself  under  another  aspect : the  mildest  drinks,  such  as  gum-water, 
which  hitherto  were  the  only  drinks  that  could  be  borne,  produce,  when  taken, 
a sensation  of  weight  in  the  epigastrium  ; if  persevered  in,  they  will  at  length 
be  discharged  by  vomiting.  The  same  may  be  said  of  the  faceulas  and  other 
mild  aliment  which  had  hitherto  constituted  the  basis  of  the  food.  Then  what 


DISEASES  OF  THE  ABDOMEN. 


275 


are  we  to  do  ? Shall  we  admit  that  the  gastric  irritation  has  again  assumed 
increased  activity,  and  shall  we  still  retain  the  severity  of  the  regimen  ? Still 
we  subject  the  patient  to  strict  diet?  In  acting  thus  we  might  aggravate  the 
symptoms  to  an  alarming  extent:  total  abstinence,  at  a moment  when  the  ex- 
hausted system  feels  acutely  the  want  of  reparation,  and  where  the  improve- 
ment in  the  state  of  the  stomach  allows  us  to  satisfy  it,  might  occasion  towards 
this  latter  organ  a secondary  irritation,  which  might  manifest  itself  by  pain  in 
the  epigastrium,  dryness  and  redness  of  the  tongue,  nausea  and  vomiting,  and 
acceleration  of  the  pulse.  For  these  effects  there  might,  in  a little  time,  be  no 
longer  a remedy,  and  the  sudden  return  of  the  gastritis  to  the  acute  state  might  be 
speedily  followed  by  death.  This  is  what  has  unfortunately  been  observed 
more  than  once  in  cases  where  persons  have  taken  for  signs  of  increased  irrita- 
tion phenomena  which  resulted  from  an  entirely  different  cause.  Then  the 
stomach  no  longer  bears  gum-water ; it  bears,  on  the  contrary,  some  aromatic 
or  bitter  preparations,  a'nd  a little  wine  of  good  quality  agrees  perfectly  well 
with  it.  Faecula  prepared  with  milk,  or  with  chicken  broth,  cannot  be  digested, 
whilst  strong  broth  will  succeed  very  well.  The  gastric  mucous  membrane 
is  then  in  the  same  case  as  the  mucous  membrane  of  the  eye,  which,  towards 
the  decline  of  some  cases  of  ophthalmia,  becomes  redder  and  more  engorged 
under  the  influence  of  mild  collyria,  and  which  soon  returns  to  its  normal  state, 
if  bathed  with  brandy,  or  touched  with  nitrate  of  silver.  It  is  because  the  ac- 
cumulation of  blood  in  a part  does  not  necessarily  imply  that  this  part  is  irri- 
tated, and  because  the  living  tissues,  in  order  that  they  be  able  to  disengage 
themselves  from  the  disease  which  has  attacked  them,  require  a certain  degree 
of  stimulation  beyond  and  short  of  which  these  tissues  can  no  longer  return  to 
their  normal  state. 

Long  experience  alone  can  teach  us  to  modify,  in  each  particular  case,  the 
general  rules  of  hygiene  which  should  be  followed  by  persons  labouring  under 
chronic  gastritis.  We  shall  make  but  one  remark  on  this  subject  ; it  regards 
the  exercise  which  is  taken  by  these  patients.  Very  often  it  is  not  proportioned 
to  their  strength,  and,  by  their  fatiguing  themselves,  they  are  prevented  from 
digesting.  Inasmuch  as  considerable  exercise  is  useful,  when  the  patients  take 
sufficient  nourishment,  in  the  same  degree  has  it  appeared  to  us  injurious  in 
the  case  of  those  who  are  kept  on  strict  diet.  In  such  cases  the  digestion  has 
all  at  once  become  easier  merely  by  obliging  the  patient  not  to  walk  after  eat- 
ing. We  have  seen  persons  who  did  not  digest  well  except  they  took  their 
meals  in  bed,  and  remained  there  all  the  time  the  process  of  chymification  was 
going  on.  We  have  attended  a lady  who  could  not  re-establish  the  functions 
of  her  stomach,  which  had  been  for  a long  time  the  seat  of  irritation,  except  by 
eating  in  a bath.  At  first  she  breakfasted  and  dined  in  this  way  ; she  then  took 
but  one  meal  so  ; after  strictly  adhering  to  this  practice  for  about  six  weeks  she 
was  completely  cured. 


CHAPTER  III. 

OBSERVATIONS  ON  SOME  AFFECTIONS  OF  THE  STOMACH,  WHICH  DO 
NOT  CONSIST  IN  AN  INFLAMMATORY  STATE  OF  THIS  ORGAN. 

The  different  alterations  of  the  stomach  considered  in  the  two  preceding  chap- 
ters, possess  this  common,  and  at  the  same  time  very  important,  character, 
namely,  that  the  antiphlogistic  treatment  is  that  which  may  be  employed  with 
most  advantage  against  them.  When  this  treatment  is  no  longer  useful,  it  is 
because  the  nature  of  the  alterations  against  which  it  was  employed,  has  been 
changed.  We  pointed  out  this  at  the  end  of  the  second  chapter. 

We  have,  with  M.  Broussais,  employed  the  term  gastrite  to  express  those 


276 


ANDltAL’S  MEDICAL  CLINIC. 


numerous  alterations  which  all  recognise  irritation  as  their  common  link,  and 
which  all  require  a treatment  exclusively  emollient. 

Still  every  affection  of  the  stomach  is  not  gastritis.  In  many  cases  its  func- 
tions may  be  disturbed  under  the  influence  of  causes  all  differing  from  those 
which  ordinarily  produce  inflammation,  and  this  disturbance  of  function  is  re- 
moved only  by  a treatment  which  must  necessarily  exasperate  it,  if  it  depended 
on  this  inflammatory  state  of  the  stomach.  Post-mortem  examination  again 
steps  in  here  to  strengthen  those  proofs  of  its  authority,  by  presenting  to  us 
cases  in  which  the  stomach  exhibited  no  trace  of  inflammation,  though  during 
life  it  had  been  the  seat  of  functional  disturbances  more  or  less  serious. 

First,  it  is  generally  admitted  that  several  diseases  of  the  nervous  centres  may 
very  much  disturb  the  functions  of  the  stomach,  occasion  profuse  and  prolonged 
vomiting,  without  our  being  able  to  detect  in  the  stomach  itself  any  appreciable 
lesion  whatever.  Numerous  instances  of  this  are  to  be  found  in  the  first  part 
of  this  work.* 

Case  1. — Dyspepsia  of  several  months  standing  ; progressive  wasting — No  appreciable  alter- 
ation in  the  stomach,  or  in  any  other  organ. 

A woman,  thirty-eight  years  of  age,  entered  the  Pitie  in  the  month  of  April, 
1831.  She  stated  that  since  the  last  seven  or  eight  months  she  entirely  lost 
her  appetite  ; every  time  she  took  food  she  felt  an  insupportable  weight  in  the 
epigastrium,  and  occasionally  rather  an  acute  pain.  From  time  to  time  she 
vomited  some  whitish  mucus.  Strong  pressure  on  the  epigastrium  produced  no 
painful  sensation  in  this  region.  The  remainder  of  the  abdomen  was  soft  and 
free  from  pain  ; the  patient  was  habitually  constipated  ; tongue  natural  ; no  dis- 
turbance of  any  other  organ  ; the  patient  was  very  much  emaciated,  and  very 
feeble.  She  mentioned  that  she  had  begun  to  lose  her  appetite  and  her  powers 
of  digestion  after  having  been  subjected  to  severe  mental  distress. 

We  considered  this  woman  as  labouring  under  chronic-gastritis,  and  in  con- 
sequence of  the  perfectly  natural  appearance  of  the  tongue,  we  apprehended  the 
existence  of  a cancerous  degeneration  of  the  sub-mucous  cellular  tissues.  We 
prescribed  milk  diet,  and  established  a seton  over  the  epigastrium.  The  woman 
wasted  away  gradually,  and  eventually  died  without  presenting  any  new  symp- 
toms. Towards  the  latter  period  of  her  life  she  even  refused  to  take  milk,  and 
admitted  nothing  else  into  her  stomach  except  a few  spoonsful  of  gum-water. 

Post-mortem.  The  brain,  lungs,  heart,  and  abdominal  viscera  were  all 
found  in  a perfectly  healthy  state,  as  also  the  trisplanchnic  and  pneumogastric 
nerves. 

Thus,  in  this  case,  anatomy  was  entirely  unable  to  reveal  to  us  the  cause  of 
the  symptoms  and  of  death.  This  stomach,  so  very  much  disturbed  in  its  func- 
tions, was  perfectly  healthy  in  its  texture. 

It  was  not,  therefore,  of  chronic  gastritis  that  this  patient  died  ; for  gastritis 
leaves  behind  it  traces  of  its  existence.  Was  there  in  this  case  neurosis  of  the 
stomach,  or  atony  of  this  organ  ? Who  could  prove  it  ? We  know  so  little  by 
what  force  chymification  is  accomplished,  that  we  cannot  appreciate  all  the 
causes  which  prevent  its  going  on. 

On  the  other  hand,  the  sympathetic  connexions  between  the  stomach  and  the 
other  organs  are  so  numerous,  that  the  disturbance  of  one  of  these  organs  must 
necessarily  modify  the  functions  of  the  stomach,  without  this  modification  being 
necessarily  an  inflammation,  or  even  simple  irritation.  May  it  not  be  in  this 
respect  the  same  with  the  gastric  mucous  membrane  as  with  the  skin?  And 

* Some  cases  are  here  detailed  by  our  author  in  which  profuse  vomiting  existed  as  the  pre- 
dominant symptom,  without  any  lesion  being  found  in  the  stomach  to  account  for  it.  These 
cases  we  have  omitted. — Tuans. 


DISEASES  OF  THE  ABDOMEN. 


277 


in  the  course  of  most  chronic  diseases  the  cutaneous  covering  is  often  found 
considerably  modified  in  its  several  secretions,  without  its  being  in  the  slightest 
degree  inflamed  or  irritated  ; why,  under  such  circumstances,  might  not  the 
functions  of  the  mucous  membrane  of  the  stomach  be  also  more  or  less  seriously 
altered  ? In  a word,  by  virtue  of  this  wonderful  law  of  synergy,  of  which  the 
animal  economy  presents  us  with  such  continual  examples,  it  seems  that  the 
functions  of  the  stomach,  in  which  the  act  of  assimilation  commences,  must 
tend  to  become  suspended,  for  this  sole  reason,  that  other  organs  of  nutritive 
life  (small  intestine,  lungs,  liver,  etc.)  have  themselves  ceased  to  fulfil  their 
functions.  Of  what  use,  in  fact,  would  it  be  that  chyme  should  be  formed,  if 
the  further  changes  of  the  aliment  could  not  be  produced,  if  it  could  become  neither 
chyle,  nor  blood,  nor  an  integral  part  of  the  tissues  of  the  individual  ? Professor 
Berard,  of  Montpellier,  seems  to  have  expressed  this  idea  with  as  much  strength 
as  accuracy,  when  he  said  that  the  system  digested  by  means  of  the  stomach. 

Besides  those  cases  in  which  the  functional  disturbances  of  the  stomach  can- 
not be  explained  by  any  change  in  the  structure  of  this  organ,  there  are  others 
wherein,  to  account  for  these  functional  disturbances,  some  lesions  of  structure 
are  found ; but  nothing  proves  that  these  lesions  are  of  an  inflammatory  nature. 

Though  it  has  been  already  laid  down  that,  in  the  stomach  as  in  many  other 
organs,  softening  is  a result  of  inflammation,  we  think  it  impossible  to  state 
positively  that  every  softening  is  really  produced  by  an  inflammatory  process. 
It  seems  to  us  that  this  softening  which  exists  in  the  gastric  mucous  membrane  in 
several  individuals  exhausted  by  chronic  diseases,  is  but  a further  degree  of 
diminution  of  consistence,  which  the  muscular  fibre,  as  also  the  blood  itself 
taken  from  a vein,  present  in  the  same  individuals.*  Certainly  it  is  proceeding 
on  a fair  and  rational  analogy,  and  not  transgressing  the  lav/s  of  a sound  philo- 
sophy, to  admit  that  in  cases  where  the  principal  agents  of  life,  the  blood  and 
nervous  system,  no  longer  nourish  and  excite  the  organs  sufficiently,  all  the 
vital  force  of  aggregation,  by  which  the  different  molecules  of  the  living  tissues 
are  held  together,  ceases  to  possess  its  natural  and  physiological  intensity  ; 
thence  the  diminished  cohesion  of  these  tissues,  and  their  greater  or  less  soften- 
ing, from  the  degree  where,  as  is  commonly  said,  there  is  Jlaccidity  of  the 
flesh , to  that  where  the  solid,  losing  the  characters  of  organisation,  manifests  a 
tendency  to  return  to  the  liquid  state.  Thus,  as  we  have  already  mentioned 
elsewhere,  the  transparent  cornea  becomes  softened,  and  is  perforated  in  animals 
who  are  put  on  a regimen  not  sufficiently  nutritive.  We  have  sometimes 
observed  a similar  phenomenon  in  adults,  and  above  all  in  children  who  have 
come  to  the  last  stage  of  marasmus,  and  in  whom,  at  the  same  time,  scorbutic 
spots  appear  in  different  parts  of  the  body.  In  these  same  children  we  also 
frequently  meet  a very  remarkable  softening  of  the  white  central  parts  of  the 
brain  (corpus  callosum,  septum  lucidum,  and  fornix),  without  this  softening 
giving  rise,  during  life,  to  any  symptom  of  cerebral  irritation  ; would  it  not  be 
reasonable  to  place  this  also  in  the  class  of  softenings  from  defect  of  nutrition, 
or  from  diminution  of  vitality?  Who  would  venture  to  affirm  that  all  soften- 
ings of  the  heart  are  the  result  of  inflammation  or  even  of  simple  irritation  ; that 
is,  according  to  M.  Rocha’s  definition,  of  an  increase  in  the  organic  action  of 
the  heart?  The  same  may  be  said  of  certain  softenings  of  the  liver  and  spleen, 
of  which  we  shall  speak  in  another  part  of  this  work.  Again,  is  the  remarkable 
softening  of  the  bones  in  rickety  patients  an  inflammation  or  an  irritation  ?t 

* This  is  not  all,  and  since  the  recent  researches  of  Dr.  Carswell,  we  can  no  longer  refuse 
to  admit  as  proved,  what  I had  already  considered  as  possible  in  my  Elements  of  Pathological 
Anatomy ; namely,  that  a great  many  cases  of  softening  of  the  stomach  do  not  take  place  till 
after  death,  being  produced  by  causes  which  do  not  act  on  the  gastric  mucous  membrane  till 
after  Hfe  has  ceased. 

t Regarding  the  nature  and  causes  of  softening  of  the  different  organs,  see  our  Elements  of 
Pathological  Anatomy. 

24 


278 


ANDRAL’S  MEDICAL  CLINIC. 


In  other  persons  the  stomach  is  not  found  softened,  properly  speaking;  but 
its  coats  are  very  much  attenuated  ; the  muscular  membrane  is  reduced  to  a few 
pale  and  thinly  scattered  fibres ; and  oftentimes  over  a greater  or  less  portion 
of  it.  The  parietes  of  the  stomach  consist  merely  of  the  peritoneal  coat,  in 
apposition  with  which  is  found  a very  thin  cellular  layer  in  place  of  the  mucous 
coat.  Like  the  instances  of  softening  mentioned  a little  while  ago,  this  attenu- 
ation, whether  of  the  mucous  membrane  alone,  or  of  all  the  coats  at  once,  is 
observed  only  in  persons  who  died  in  a state  of  marasmus,  worn  out  by  some 
chronic  disease.  Only  once  we  observed  it  in  a young  girl  who  was  not  at  all 
emaciated,  and  who  entered  the  hospital  with  the  symptoms  of  acute  menin- 
gitis, of  which  she  died.  But  in  this  case,  we  do  not  know  whether,  before 
the  appearance  of  the  cerebral  affection,  signs  of  gastric  disease  did  not  exist 
for  a greater  or  less  time. 

It  may  be  readily  conceived  that,  if,  in  a certain  number  of  cases,  this  attenu- 
ation of  the  stomach  comes  on  like  that  of  the  muscles  at  an  advanced  period  of 
several  chronic  diseases,  there  are  other  cases  wherein  this  same  attenuation  is 
the  primary  disease. 

Should  some  persons  be  disposed  to  consider  the  attenuation,  and  real  atrophy 
of  the  gastric  parietes  now  under  consideration  as  one  of  the  numerous  results 
of  chronic  inflammation,  we  would  ask  them  whether  they  also  think  that  the 
very  great  attenuation  of  the  cranial  bones  often  observed  in  old  persons  should 
be  attributed  to  an  inflammatory  process? 

We  have  been  endeavouring  to  establish  by  proofs  derived  from  anatomy, 
that  the  stomach  may  present  a great  number  of  disturbances  in  its  functions, 
which  do  not  depend  on  an  inflammatory  state  of  this  organ.  Let  us  not  then 
be  astonished,  if,  in  a considerable  number  of  patients,  we  see  symptoms  more 
or  less  similar  to  those  which  characterise  chronic  gastritis,  become  permanent 
and  even  aggravated  by  the  continuance  of  a purely  antiphlogistic  treatment,  and 
yield  on  the  contrary  to  medicines  of  another  description.  It  is  because  those 
symptoms  were  not  produced  by  gastritis,  but  by  other  morbid  states  of  the 
stomach,  the  nature  of  which  we  cannot  always'  determine,  but  which  experience 
has  taught  us  to  combat  by  certain  therapeutic  means. 

Thus,  this  particular  affection  of  the  stomach,  designated  gastric  disturbance 
( embarras  gastriqiie ),  is  certainly  not  gastritis.  What  its  real  nature  is  we  know 
not;  but  what  is  beyond  all  doubt  is,  that  this  affection,  w'hen  it  really  exists, 
resists  bloodletting,  and  yields  to  stimulating  cathartics. 

We  are  now  taking  into  account  the  cases  in  which,  whether  in  hospital,  or 
in  private  practice,  we  have  seen  the  health  re-established  after  evacuations  ex- 
cited both  upwards  and  downwards  in  persons  in  whom  derangement  was  indi- 
cated by  the  following  signs  : for  eight  or  fifteen  days  to  a month  they  had  no 
appetite  ; there  was  an  habitual  bad  taste  in  the  mouth  : the  tongue  which  was 
broad  and  pale  at  the  apex  and  edges,  was  covered  with  a whitish  or  yellowish 
coat,  without  this  coat  presenting  any  red  points  ; the  stools  were  irregular, 
sometimes  few  and  of  great  consistence,  sometimes  more  frequent  and  soft; 
oftentimes  a sense  of  tightness  or  of  weight  was  felt  in  the  epigastrium,  and  in 
some  there  was  nausea.  Further,  there  was  general  illness  more  or  less  marked, 
a feeling  of  fatigue,  the  face  was  yellow,  and  drawn ; the  eyes  sunk  ; the  head 
was  often  painful.  We  have  often  seen  this  group  of  symptoms  resist  the  ap- 
plication of  leeches,  or  mere  attention  to  diet,  or  the  use  of  diluent  drinks,  and 
then  be  instantly  removed  by  a vomit  or  purgative.  Are  there  in  such  cases 
saburrse  in  the  alimentary  canal  ? Is  there  a vitiated  modification  of  the  secretion 
of  the  gastro-intestinal  mucus,  whether  in  respect  to  its  quantity,  or  its  quality  ? 
Are  the  unknown  powers,  whose  concurrence  is  necessary  for  the  performance 
of  digestion,  altered?  And  do  emetics  and  purgatives  restore  these  powers  by 
exciting  the  intestinal  tube  and  its  appendages?  Do  they  produce  a beneficial 


DISEASES  OF  TIIE  ABDOMEN. 


279 


change  in  the  secretion  of  the  liver  and  pancreas?  We  know  not;  but  the  good 
effects  of  such  treatment  in  the  cases  now  alluded  to,  and  the  inefficacy  of  anti- 
phlogistics  in  these  same  cases,  are  beyond  all  manner  of  doubt.  (See  the  pre- 
ceding part  of  this  work.) 

Before  we  pass  to  another  series  of  facts,  we  shall  mention  a case  in  which  a 
very  intense  headach  connected  with  symptoms  of  gastric  disturbance,  after 
having  been  ineffectually  treated  by  bleeding,  disappeared  after  spontaneous 
evacuations  up  and  down. 

Case  2. — Signs  of  gastric  and  intestinal  disturbance — Inefficacy  of  bloodletting — Recovery 
after  spontaneous  bilious  discharges  up  and  down. 

A man,  about  twenty-two  years  of  age,  had  been  for  about  three  weeks  affected 
with  a very  painful  frontal  headach,  and  very  frequent  attacks  of  dizziness,  when 
he  entered  the  Charite.  Since  that  time  he  had  complete  loss  of  appetite,  bitter 
taste  in  the  mouth,  and  great  constipation. 

When  we  saw  him,  his  countenance  was  expressive  of  fatigue ; the  tongue  wa& 
of  a uniform  white  colour,  and  exempt  from  all  appearance  of  redness;  the  ab- 
domen was  in  every  part  soft  and  free  from  pain  ; pulse  a little  frequent  without 
the  skin  being  hot.  Since  the  preceding  day  he  experienced  attacks  of  dizziness 
sufficient  to  prevent  him  from  standing  up  or  walking;  he  compared  his  pain  of 
head  to  the  sensation  produced  on  his  forehead  by  violent  blows  of  a hammer. 
Eight  leeches  were  applied  to  each  side  of  the  neck,  and  two  days  after  he  was 
bled  from  the  arm  (the  blood,  which  came  from  a iarge  orifice,  united  into  a 
large  coagulum  without  being  buffed).  No  improvement  followed.  During  the 
three  following  days,  pediluvia,  lavements,  and  diluent  ptisans  were  resorted  to 
without  any  relief. 

Seven  days  after  his  admission  the  state  of  the  patient  was  still  the  same  ; 
twelve  more  leeches  were  applied  to  the  neck  without  producing  any  change. 
On  the  eighth  day,  about  a month  after  this  person’s  health  became  deranged,  he 
vomited  spontaneously  a great  quantity  of  greenish  bile,  and  in  the  course  of 
the  day  he  went  several  times  to  stool : the  alvine  evacuations  consisted  of  a 
very  yellow  liquid  substance,  and  were  not  attended  with  any  pain  ; in  the 
evening  the  headach  and  dizziness  were  sensibly  diminished,  and  on  the^next 
day  they  were  entirely  gone.  On  the  three  following  days  profuse  bilious- 
diarrhoea  took  place,  it  then  ceased  spontaneously,  as  it  had  commenced. 
Thenceforward  the  tongue  became  clean,  the  bad  taste  in  the  mouth  disappeared, 
the  appetite  returned,  and  the  patient  soon  left  the  hospital. 

In  this  case  may  we  not  reasonably  ask  ourselves  whether  similar  evacuations, 
artificially  excited,  would  not  have  hastened  the  return  of  health  ? There  is 
another  morbid  state  of  the  stomach  which  does  not  manifest  itself  by  the  same 
symptoms  as  the  preceding,  which,  like  it,  becomes  aggravated  by  the  anti- 
phlogistic treatment,  properly  so  called,  and  which,  yielding  to  a decidedly 
tonic  treatment,  may  be  considered  as  an  asthenic  state  of  this  organ. 

This  asthenic  state  may  succeed  chronic  gastritis  and  be  one  of  its  termina- 
tions ; this  we  have  already  proved.  It  may  be  primary  without  being  con- 
nected with  any  other  affection,  and  without  any  appreciable  cause  having  given 
rise  to  it.  Again,  it  is  sometimes  dependent  on  general  debility  of  the  entire 
system,  and  it  succeeds  causes  which  have  weakened  this  latter  organ  more  or 
less  seriously  : thus  it  is  often  observed  to  occur  after  excessive  indulgence  in 
venery  and  principally  after  masturbation. 

The  individuals  in  whom  the  derangement  of  the  functions  of  the  stomach  is 
owing  to  an  asthenic  state  of  this  organ  cannot  eat  without  experiencing  a painful 
sensation,  which  is  not  identical  in  all.  Some  complain  of  a very  troublesome 
weight  in  the  epigastrium  ; others  experience  a sensation  of  tension  or  swelling 
in  this  same  region,  whilst  others  again  complain  principally  of  suffocation. 
As  long  as  digestion  is  going  on,  they  feel  general  debility,  and  several  fall 


2S0 


ANDltAL’S  MEDICAL  CLINIC. 


asleep.  The  nature  of  the  food  possesses  considerable  influence  over  the 
greater  or  less  difficulty  with  whiph  they  digest ; thus  the  digestion  of  pulse, 
white  meats,  and  especially  veal,  occasions  much  more  pain  to  the  stomach 
than  that  of  beef  or  mutton.  They  find  themselves  much  better  after  drinking 
a little  wine  in  water  at  their  meals,  than  pure  water;  the  latter  often  excites 
in  them  a sensation  of  weight  which  is  removed  by  wine.  Instead  of  plain 
water  we  may  then  add  some  Seltzer  water  to  the  wine  with  great  advantage. 
In  some  cases  it  becomes  necessary  to  give  some  spoonsful  of  Spanish  or  quin- 
quina wine  at  the  end  of  each  meal.  The  success  of  this  regimen  very  well 
illustrates  the  nature  of  the  gastric  affection.  In  such  cases  the  tongue  is  free 
from  redness  ; it  is  pale  at  its  edges  as  also  at  its  centre  ; except  at  the  time  of 
digestion  the  epigastrium  is  free  from  pain  ; sometimes,  however,  it  contains 
an  enormous  quantity  of  gas  by  which  it  is  distended,  and  which  occasions 
temporary  pain.  The  patients  do  not  feel  any  thirst;  they  are  not  hungry, 
properly  speaking,  and  they  are  apprised  of  the  necessity  of  taking  food  either 
by  a sort  of  painful  sensation  in  the  epigastrium,  or  by  a kind  of  general  illness, 
of  which  their  own  experience  points  out  the  cause,  or  by  a feeling  of  faintness. 
There  usually  exists  obstinate  constipation,  and  the  stools  are  often  devoid  of 
colour.  In  some  cases  gentle  purgatives  are  necessary  to  overcome  this  con- 
stipation ; their  use,  repeated  with  prudence,  renders  the  stools  regular,  and 
gives  them  a better  colour,  and  at  the  same  time  the  stomach  itself  is  improved  ; 
in  such  cases  we  have  employed  with  advantage  the  infusion  of  rhubarb  ; we 
would  carefully  avoid  the  use  of  oily  purgatives,  as  the  stomach  might  not  so 
easily  bear  them.  Sometimes  diarrhoea  takes  place  by  using  pulse  and  under- 
done meat.  Oftentimes  it  is  not  without  much  difficulty  that  the  digestive 
powers  return  to  their  normal  state.  It  is  then  no  longer  sufficient  to  assist  the 
process  of  digestion  by  more  stimulating  food  ; it  is  also  necessary  to  administer 
certain  medicines  which  act  in  the  same  way.  The  different  preparations  of 
quinquina  seem  to  us  in  such  cases  peculiarly  applicable  ; they  not  only  pos- 
sess a beneficial  influence  on  the  stomach  itself,  but  they  also  produce  good 
effects  on  the  remainder  of  the  system,  when  this  participates  in  the  debility 
with  which  the  stomach  is  affected.  It  sometimes  happens  that  this  latter  organ 
has  recovered  the  integrity  of  its  functions,  and  yet,  though  digestion  apparently 
goes  on  in  a favourable  manner,  the  patient  does  not  recover  flesh  and  strength. 
We  were  inclined  to  admit  this  in  a young  man  whom  we  attended  some  time 
since.  Being  attacked  at  first  with  an  affection  which  was  considered  as  gastric 
irritation,  he  was  for  a long  time  subjected  to  a very  spare  regimen  ; his  diet 
consisted  almost  exclusively  of  milk.  Still  a period  came  when  the  milk  could 
no  longer  be  digested,  and  as  its  use  was  still  continued  for  some  time  longer, 
the  patient,  who  now  took  no  aliment  but  such  as  was  no  longer  assimilated, 
fell  rapidly  into  the  last  stage  of  marasmus  and  debility.  Still  the  tongue  was 
natural,  and  there  was  no  fever  ; but  the  patient  pined  away  so  rapidly,  that 
there  was  some  apprehension  that  his  dissolution  was  at  hand  ; in  this  state 
of  things  his  diet  was  changed  ; instead  of  milk  and  fieculas  prepared  with 
water,  he  took  animal  jellies,  chicken,  and  soon  after  mutton  ; all  this  food  was 
digested  perfectly  well ; its  employment  was  therefore  continued,  and  the 
patient  soon  became  able  to  take  very  substantial  food,  without  the  stomach 
suffering  from  it  in  the  slightest  degree.  Still  his  general  state  was  not  im- 
proved ; the  emaciation  remained  the  same,  and  the  debility  did  not  diminish. 
We  directed  that  the  patient,  who  thought  to  increase  his  strength  by  taking 
carriage  exercise  and  walking  about  his  chamber,  should  discontinue  to  go 
out ; we  also  directed  that  he  should  remain  as  quiet  as  possible,  that  he  should 
take  all  his  meals  in  bed,  and  that  he  should  remain  without  stirring  from  it,  in 
order  to  digest;  for  we  deemed  it  necessary  to  spare  his  strength  in  every 
possible  way.  At  the  same  time  we  directed  him  to  take  alternately  an  infusion 
of  bark,  Seguin  wine,  sulphate  of  quina  both  by  the  mouth  and  in  the  form  of 


DISEASES  OF  THE  ABDOMEN. 


281 


lavements,  pills  consisting  of  musk,  extract  of  gentian,  and  subcarbonate  of 
iron  ; several  times  a-day  stimulating  frictions  were  employed  on  the  extremi- 
ties and  trunk.  We  discovered  no  trace  of  lesion  in  any  organ,  and  we  began 
to  think  that  the  case  was  one  of  diminished  power  of  nutrition.  For  nearly 
two  months,  during  which  time  digestion  continued  perfectly  good,  the  general 
state  underwent  no  improvement ; towards  the  end  of  this  time  the  limbs  be- 
came infiltrated,  and  we  detected  commencing  ascites ; we  then  began  to  despond, 
and  dreaded  that  some  latent  alteration  of  the  liver  was  the  cause  of  this  com- 
mencing dropsy.  We  persevered,  however,  in  the  employment  of  the  tonic 
treatment,  and  at  last  the  time  came  when  the  emaciation  and  debility,  being 
now  somewhat  diminished,  apprised  us  that  the  organs  were  beginning  to 
assimilate  the  materials  of  nutrition  sent  to  them  by  the  stomach.  As  soon  as 
ever  the  patient  began  to  acquire  a little  more  strength,  we  made  him  go  out  in 
a carriage,  recommending  him,  at  the  same  time,  to  avoid  over  exertion.  His 
flesh  and  strength  returned  gradually,  and  he  is  now  perfectly  restored. 

Does  it  not  appear  that,  in  this  case,  the  essential  lesion  principally  affected 
that  power  or  force  in  virtue  of  which  the  living  tissues  assimilate  the  materials 
destined  for  their  reparation  ? In  vain  had  the  stomach  recovered  the  power 
of  digesting  the  most  nutritive  materials  : the  system  derived  no  benefit  there- 
from. It  is  to  be  observed  that  as  long  as  the  disease  remained  stationary,  the 
urine  presented  a very  copious  deposit,  consisting  of  uric  acid  and  several  cal- 
careous salts.  This  deposit  diminished  from  the  moment  that  a slight  alteration 
began  to  be  observable.  Was  it  the  materials  of  nutrition  furnished  by  the 
aliment,  which,  instead  of  being  assimilated  to  the  organs,  were  separated  from 
the  blood  within  the  veins  ? we  know  that  when  there  is  an  exuberance  in  the 
materials  of  nutrition,  the  urine  becomes  loaded  with  uric  acid  and  phosphates. 
Was  there  not  in  this  case  a relative  exuberance  ? 

Here  is  another  fact  in  which  the  disturbance  of  the  functions  of  the  stomach 
seems  to  have  been  occasioned  by  an  asthenic  state  of  this  organ,  and  where 
this  asthenic  state  was  also  dependent  on  the  general  state  of  the  individual, 
and  particularly  on  the  state  of  innervation,  on  which  the  cause  of  the  disease 
must  have  acted  in  the  first  instance. 

Case  3. — Symptoms  of  chronic  gastritis — No  amendment  from  the  employment  of  the  anti- 
phlogistic treatment  and  strict  regimen — More  substantial  aliment — Cure. 

A young  man,  about  twenty  years  of  age,  of  a strong  constitution,  was  in  the 
enjoyment  of  good  health,  when  he  gave  himself  up  to  excessive  masturbation. 
Some  time  after  he  had  commenced  to  indulge  in  this  destructive  habit,  his 
digestion,  which  till  then  had  been  good,  became  deranged  ; he  felt,  after  eating, 
a disagreeable  weight  in  the  epigastrium  ; at  the  same  time  he  wasted  away, 
and  a very  distressing  frontal  headach  made.its  appearance.  These  symptoms 
had  existed  for  some  months,  when  a physician  was  consulted ; the  patient, 
alarmed  at  the  state  of  his  health,  left  off  the  practice  of  masturbation,  and, 
notwithstanding  the  functions  of  the  stomach  were  not  restored,  the  headach 
still  continued.  He  was  considered  to  labour  under  chronic  gastritis,  conse- 
quently the  strictest  regimen  was  prescribed,  and  leeches  were  several  times 
applied  to  the  epigastrium,  all  without  any  advantage  ; the  headach  did  not 
diminish,  nor  the  symptoms  of  gastric  disturbance.  We  then  changed  the 
treatment ; the  patient  began  to  lake  more  substantial  food  ; broths  and  animal 
food  were  ordered.  A very  little  time  after  he  had  commenced  this  new  regimen, 
the  headach  disappeared,  the  epigastric  weight  ceased  to  be  any  longer  felt,  and 
the  patient  was  soon  restored  to  perfect  health.* 

* Facts  more  or  less  similar  to  this  may  be  found  in  an  excellent  work  on  nervous  gastralgia, 
by  Dr.  B arras. 

24* 


282 


ANDRAL’S  MEDICAL  CLINIC. 


From  this  fact  we  think  we  may  conclude  that  the  gastric  symptoms,  which  so 
often  follow  venereal  excesses,  and  masturbation  in  particular,  should  not  be  con- 
sidered as  invariably  and  necessarily  owing  to  gastric  irritation.  The  case  just 
cited  induces  us  on  the  contrary  to  think  that,  far  from  the  stomach  being  then 
irritated,  it  was  really  debilitated.  It  ceased  to  receive  that  portion  of  nervous 
influence  necessary  for  the  normal  performance  of  its  functions.  It  is  quite  certain 
that  those  venereal  excesses  have  the  effect  of  diminishing  the  energy  of  the 
nervous  system,  and  of  weakening  or  depriving  the  influence  of  this  system  on  the 
different  organs  of  animal  and  nutritive  life.  Why  should  not  the  digestive 
powers  be  also  debilitated  in  this  case,  as  well  as  the  muscular  strength,  and  the 
intellectual  or  sensorial  faculties  ? We  do  not  now  mean  to  say  that  inflamma- 
tion may  not  arise  under  such  circumstances  ; we  think,  on  the  contrary,  that 
in  consequence  of  the  normal  action  of  the  nervous  centres  being  modified,  these 
different  organs  more  readily  and  more  easily  become  the  seat  of  congestions, 
irritations,  and  of  real  inflammations  ; but  on  the  one  hand  it  must  not  be  sup- 
posed, that  all  the  symptoms  which  then  come  on  can  be  occasioned  only  by 
them  ; and  on  the  other  hand  it  must  not  be  forgotten,  that  even  when  they  do 
exist,  their  treatment  should  be  modified  according  to  the  particular  conditions 
under  which  these  inflammations  have  become  developed. 

In  this  case  it  is  quite  clear  that  it  is  not  to  the  mere  removal  of  the  deter- 
mining cause  of  the  disease  that  the  cure  was  owing;  for  the  individual  had  for 
a long  time  discontinued  the  practice  of  masturbation,  and  still  the  disturbance 
of  the  digestive  functions  continued  ; we  have  no  doubt  but  this  disturbance 
was  kept  up  by  the  debilitating  treatment  to  which  the  patient  was  at  first  sub- 
jected. 

Besides  these  cases  in  which  the  disturbance  of  the  functions  of  the  stomach 
seems  to  depend  on  an  asthenic  state  of  this  organ,  there  are  others  wherein 
this  latter  cause  can  no  longer  be  satisfactorily  proved,  and  wherein  the 
gastric  symptoms  are  usually  referred  to  a neurosis.  Such  is  the  following 
case  : 

A young  lady,  for  whom  we  had  been  consulted  during  the  winter  of  1833, 
had  been  frequently  during  her  life  affected  rather  seriously  with  respect  to  her 
stomach.  When  we  saw  her  she  could  not  digest  any  food  without  feeling 
acute  pains  in  the  epigastrium.  She  soon  gave  up  all  sort  of  nourishment ; she 
was  unable  to  bear  the  lightest  food  ; vomiting  set  in,  and  the  patient  became  so 
debilitated  and  emaciated,  that  she  was  considered  as  dying.  The  tongue  re- 
tained its  natural  appearance.  Amidst  this  increasing  debility,  the  patient  was 
distressed  by  a very  acute  feeling  of  hunger,  but  in  vain  did  we  strive  to  satisfy 
it.  The  lightest  food  given  to  her  was  thrown  up  by  vomiting  ; or,  if  it  was 
retained,  its  digestion  occasioned  to  the  patient  a state  of  indescribable  suffering. 
M.  Recamier,  who  was  then  consulted,  thought  that  cold  affusions  might  be 
beneficial,  and  he  considered  himself  warranted  in  hoping,  that,  as  soon  as  their 
employment  was  commenced,  the  digestive  functions  would  be  re-established, 
and  that  the  patient  might  be  able  to  bear  some  beef-tea,  in  which  bread  was 
steeped.  The  other  physicians  in  attendance  agreed  to  M.  Recamier’s  proposi- 
tion. 

The  patient  being  seated  in  an  empty  bath,  water  of  the  temperature  of  22°  R. 
was  poured  over  her  entire  body,  for  about  five  minutes.  She  bore  this  first  af- 
fusion very  well;  but  when  replaced  in  the  bed  she  felt  herself  so  very  ill  that 
she  refused  to  take  any  species  of  food.  On  the  following  day,  the  affusion  was 
recommenced,  and  this  time  the  patient  was  actually  forced  to  take  a tolerably 
large  slice  of  bread  in  some  beef  soup  immediately  after.  The  affusions  were 
continued,  and  after  each  of  them  the  patient  was  made  to  take  a meal  of  a still 
more  substantial  quality  ; she  very  soon  became  able  to  digest  a mutton-chop  ; 
her  strength  was  perfectly  restored,  and  in  this  way  an  affection  was  removed 


DISEASES  OF  THE  ABDOMEN.  283 

which  had  appeared  sufficiently  alarming  to  induce  us  to  announce  to  the  family 
her  approaching. dissolution. 

The  region  of  the  stomach,  sometimes  becomes  the  seat  of  very  acute  pain, 
which,  unaccompanied  by  any  other  alarming  phenomenon,  still  seems  to  be 
connected  with  mere  disturbance  of  the  innervation.  Thus  we  have  had  an  oppor- 
tunity of  seeing  a young  girl  extremely  hysterical,  who  from  time  to  time  felt 
on  a sudden,  a little  below  the  ensiform  cartilage,  a lacerating  pain,  which,  when 
left  to  itself,  generally  lasted  about  30  hours,  and  was  relieved  much  sooner, 
when  the  patient  was  made  to  take  a mixture,  the  active  ingredients  of  which 
were  aether  and  Rousseau’s  laudanum.  This  girl  had  a very  good  stomach,  and 
her  pain  had  scarcely  disappeared,  when  she  commenced  to  eat,  as  usual,  without 
any  thing  unpleasant  resulting  from  it. 

We  knew  another  woman  about  fifty  years  of  age,  in  whom  a lumbago,  which 
habitually  tormented  her,  was  from  time  to  time  succeeded  by  an  acute  pain  in 
the  epigastrium  ; this  continued  for  some  days,  it  then  disappeared  spontane- 
ously, and  the  loins  again  became  the  seat  of  pain. 

A man  consulted  MM.  Chomel,  Margolin,  and  myself,  in  the  summer  of 
1833,  for  an  extraordinary  affection,  of  which  the  following  are  the  principal 
traits  : this  person,  who  was  about  sixty  years  of  age,  and  of  an  excellent  con- 
stitution, and  had  always  led  a sober,  regular  life,  felt  for  the  first  time,  about 
twelve  years  before,  an  acute  lacerating  pain  in  the  epigastrium.  The  pain  con- 
tinued for  several  hours,  and  then  ceased  ; he  hadneverfelt  the  least  uneasiness 
with  respect  to  the  stomach  ; it  had  scarcely  ceased,  when  he  was  able  to  digest 
as  well  as  before.  Since  that  time,  this  pain  reappeared  very  frequently,  at 
greater  or  less  intervals.  For  some  time  it  returned  periodically,  regularly  as- 
suming the  tertian  type  ; at  another  period,  it  presented  itself  every  eight  days; 
most  frequently  it  observed  no  regularity  in  its  returns.  Its  duration  was  very 
variable,  sometimes  an  hour  did  not  elapse  between  its  appearance  and  its  ter- 
mination, sometimes  it  continued  from  twelve  to  thirty  hours  ; once  it  lasted  for 
upwards  of  one  hundred  hours,  and  this  protracted  attack  was  followed  by  jaun- 
dice ; this  was  the  only  time  that  any  disturbance  appeared  with  respect  to  the 
biliary  apparatus.  This  pain  returned  several  times  without  any  assignable 
cause  ; under  other  circumstances  mental  exertion  seemed  to  exercise  some  influ- 
ence over  its  reappearance.  The  patient  vomited  a certain  quantity  of  clear 
mucus,  the  expulsion  of  which  seemed  to  relieved  him.  We  witnessed  one  of 
these  attacks  : the  patient  who  was  sitting  up  in  his  bed,  the  trunk  being  inclined 
forwards,  expressed  by  loud  cries  the  violent  pain  which  he  felt ; this  pain  was 
seated  immediately  below  the  ensiform  cartilage  ; it  did  not  extend  into  the  hy- 
pochondria, and  inferiorly  it  did  not  reach  as  far  as  the  umbilicus.  It  was  not 
perceptibly  increased  by  pressure.  The  countenance  was  pale,  and  the  features 
became  very  much  altered;  the  skin,  which  was  cold,  was  covered  with  a 
clammy  sweat;  the  pulse  was  very  small,  and  not  more  than  fifty.  We  gave 
him  some  acetate  of  morphia  in  the  form  of  pills.  This  attack  did  not  last  long* 
The  next  morning  the  patient  returned  to  his  habitual  state  of  health  which  was 
excellent ; he  had  a good  appetite,  and  was  able  to  take  his  ordinary  meals. 
It  was  evident  that  at  the  time  of  the  attack,  no  organ  was  suffering  in  this  case. 
Did  the  patient  labour  under  neuralgia,  either  of 'the  pneumogastric  nerves,  or 
of  the  solar  plexus  ? Antispasmodics  and  narcotics  seemed  the  most  beneficial 
remedies,  and  it  was  these  we  prescribed  to  the  patient.  However,  after  the 
lapse  of  some  months,  and  after  a very  severe  attack,  he  discharged  a calculus 
of  moderate  size  by  stool,  from  which  time  he  became  quite  well. 

There  is  another  .ystem,  which  in  certain  cases  seems  connected  with  mere 
nervous  disturbance  of  the  stomach  ; that  is  vomiting.  We  have  already  cited 
the  remarkable  case  of  a woman  who  had  copious  and  long  protracted  vomiting, 
which  was  not  accounted  for  by  any  appreciable  disorder  in  the  texture  of  the 
stomach.  We  have  met  other  individuals,  also,  in  whom  the  vomiting  did  not 


2 S4 


ANDRAL’S  MEDICAL  CLINIC, 


appear  to  be  connected  with  a gastritis,  or  any  other  organic  change  of  the 
stomach.  We  have  seen,  for  instance,  two  women,  aged  from  twenty-seven  to 
thirty  years,  who  fora  considerable  time  laboured  under  palpitation  of  the  heart, 
so  severe  that  we  apprehended  the  actual  or  approaching  existence  of  an  aneu- 
rism of  that  organ.  However,  these  palpitations  ceased,  and  no  disturbance  any 
longer  remained  with  respect  to  the  circulating  apparatus.  But  in  both  these  indi- 
viduals a little  time  after  the  action  of  the  heart  became  regular,  there  came  on 
vomiting  which  was  soon  repeated  every  time  they  tried  to  take  any  food.  This 
vomiting  continued,  on  one  of  them  for  the  space  of  twenty  days,,  in  the  other 
for  nearly  two  months.  The  latter  individual,  who  was  now  reduced  to  the 
last  stage  of  marasmus,  appeared  doomed  to  immediate  dissolution.  In  both, 
however,  these  obstinate  attacks  of  vomiting  disappeared  ; solid  substances, 
such  as  biscuits  and  the  like,  could  be  retained  at  a time  when  milk  and  chicken- 
broth  were  rejected  ; there  was  scarcely  any  interval  between  the  time  when 
the  vomiting  ceased,  and  that  when  their  stomach  was  able  to  digest  everything 
with  impunity.  Thus,  their  recovery  was  very  rapid.  During  their  illness 
the  tongue  had  always  remained  natural,  the  epigastrium  was  free  from  pain, 
and  the  pulse  was  not  frequent,  the  sensation  of  hunger  had  also  been  always 
retained.  These  certainly  were  not  either  the  symptoms,  course,  nor  mode  of 
termination  of  a gastritis.  In  both  these  cases,  the  subnitrate  of  bismuth 
appeared  to  us  to  be  the  medicine  which  contributed,  most  to  the  cessation  of 
the  vomiting.  Before  it,  opium  had  been  employed  without  any  good  effect; 
at  first,  we  sprinkled  some  acetate  of  morphine  over  the  surface  of  a blister  ; we 
then  gave  it  internally. 

Independently  of  all  these  functional  disturbances  of  the  stomach  which 
recognise  so  many  different  causes,  and  constitute  so  many  different  diseases, 
may  this  organ  be  affected  also  under  the  influence  of  an  entirely  specific  cause, 
such  as  the  venereal  virus  ? Many  cases  present  themselves  wherein  the  symptoms 
of  a gastric  affection  disappear  under  the  influence  of  mercurial  preparations  ? 
We  propose  these  questions,  without  being  able  to  solve  them  ; we  shall  cite 
the  two  following  cases,  as  bearing  on  these  points ; they  seem  particularly 
deserving  of  consideration. 

Case  4. — Affection  of  the  stomach,  presenting  all  the  symptoms  of  an  organic  lesion  of  this 
. viscus,  cured  during  the  use  of  mercury. 

A female,  twenty-nine  years  of  age,  whose  father  had  died  of  an  organic 
affection  of  the  stomach,  was  married  at  the  age  of  seventeen,  and  having  had 
four  children  the  first  five  years  of  her  marriage,  contracted  about  three  years 
ago  a gonorrhoea,  which,  after  having  been  treated  in  its  acute  stage  by  demul- 
cent drinks,  baths',  and  soothing  injections,  was  then  stopped  by  the  use  of  the 
astringent  mixture  known  by  the  title  of  Choppairt’s  mixture. 

All  discharge  had  ceased  ; the  patient  presented  no  general  or  local  symptom 
indicative  of  the  existence  of  the  syphilitic  virus  ; she  assured  us  that  she  had 
never  enjoyed  such  excellent  health  ; from  time  to  time  only  some  pimples 
appeared  on  the  external  labia,  which  disappeared  very  speedily  under  the  use 
of  baths  and  lotions  of  marsh-mallow  water.  Their  frequent  reappearance 
attracted  my  attention  ; when  carefully  examined,  they  seemed  to  present  a 
dartrous  appearance.  The  patient  was  put  on  the  use  of  cooling  drinks,  and 
she  took  twenty  Barrege  baths;  from  that  time  the  pimples  did  not  reappear. 
For  two  years  I continued  to  see  this  lady  very  frequently,  and  I know  that  her 
health  was  not  for  a moment  impaired.  At  the  end  of  these  two  years  she 
became  a prey  to  strong  mental  emotions  ; her  life  was  crossed  by  annoyances 
of  every  kind.  After  this  period  she  began  to  lose  flesh  ; her  complexion  left 
her  ; her  face  assumed  a leaden,  livid  appearance  ; most  serious  symptoms  soon 
appeared  with  respect  to  the  digestive  organs ; the  appetite  was  lost ; the  food 
taken  into  the  stomach  occasioned  a painful  sensation,  the  seat  of  which  the 


DISEASES  OF  THE  ABDOMEN. 


285 


patient  referred  to  the  parts  below  the  xiphoid  cartilage  ; her  food  was  some- 
times vomited  a few  hours  after  having  been  taken.  The  epigastric  region, 
when  examined  carefully,  presented  no  appearance  of  tumour ; it  was  sensible 
on  pressure  ; violent  eructations  took  place;  the  tongue  was  habitually  whitish  ; 
stools  natural ; pulse  very  rarely  frequent ; skin  dry ; the  menses  returned 
every  month  as  usual,  but  much  less  copiously.  Everything  seemed  to  announce 
chronic  gastritis  in  this  patient.  No  symptom  excited  any  suspicion  that  the 
liver  was  affected.  Leeches  were  frequently  applied  over  the  epigastrium  ; 
they  several  times  seemed  to  diminish  the  sensibility  of  the  stomach.  This 
region  was  covered  with  emollient  fomentations  ; tartar  emetic  plaster  was 
tried,  and  blisters  over  the  epigastrium  ; a cautery  was  applied  to  the  arm ; the 
application  of  ice  to  the  epigastrium  oftentimes  suspended  the  vomiting ; every 
species  of  opiate  taken  internally  was  soon  vomited  ; the  patient  took  nothing 
but  some  emollient  drinks. 

Notwithstanding  all  the  efforts  of  art  the  disease  made  frightful  progress. 
Five  months  after  the  appearance  of  the  first  symptoms  daily  vomitings  took 
place;-  every  species  of  food,  whether  solid  or  liquid,  was  in  a great  measure 
thrown  up  a little  time  after  being  taken  ; asses’  milk  was  the  only  nutritive 
drink  which  could  now  be  digested.  We  despaired  of  being  able  any  longer  to 
check  the  progress  of  this  deplorable  affection,  when  one  day  the  patient  com- 
plained of  a distressing  sense  of  heat  in  the  throat,  and  of  a difficulty  in  swallow 
ing.  The  inspection  of  the  parts  soon  detected  on  the  posterior  wall  of  the 
pharynx  an  ulcer  of  some  breadth,  and  of  a rounded  form,  the  appearance  of 
which  resembled  that  of  syphilitic  ulcers  ; there  was  no  other  venereal  symp- 
tom present.  We  then  asked  ourselves  whether  the  gastric  affection  which 
was  hurrying  the  patient  to  the  grave,  might  not  be  owing  to  a syphilitic  taint. 
However  hazardous  this  idea  was,.  I still  adhered  to  it,  it  being  the  only  chance 
of  recovery  left  to  the  patient,  and  because  that  under  any  circumstances  the 
inconveniences  arising  from  an  antivenereal  treatment,  when  conducted  with 
judgment  and  discretion,  could  not  be  at  all  compared  to  the  advantages  which 
would  result  from  it  if  judiciously  employed.  I consequently  recommended  the 
use  of  mercurial  pills,  each  of  which  contained  an  eighth  of  a grain  of  deuto- 
chloride  of  mercury.  I commenced  with  one  pill,  which  was  taken  at  night ; 
I increased  them  one  by  one,  half  in  the  morning  and  half  at  night,  to  the  num- 
ber of  six  only.  I directed  her  to  drink  in  the  morning  some  barley-water 
containing  milk,  which  she  did  not  always  vomit;  this  treatment  was  continued 
for  forty  days.  At  first,  no  sensible  improvement  took  place;  it  was  certain, 
however,  that  the  mercury  taken  into  the  stomach  did  not  exasperate  the  former 
gastric  symptoms,  and  that  the  state  of  the  patient  did  not  become  worse. 
Towards  the  twenty-fifth  day  the  vomiting  became  less  frequent;  the  stomach 
seemed  to  digest  somewhat  better ; strength  seemed  to  return  ; the  appearance 
of  the  countenance  was  not  so  leaden.  From  the  thirtieth  to  the  fortieth  day 
the  amendment  could  not  be  questioned  ; it  was  principally  marked  in  the  infre- 
quency of  the  vomiting.  Encouraged  by  this  success,  I then  combined  the  use 
of  frictions  ; the  lower  extremities  were  rubbed  at  first  every  third  day,  and  then 
every  second  day,  with  a drachm  of  strong  mercurial  ointment.  After  the  twelfth 
rubbing  the  state  of  the  patient  was  entirely  changed.  The  vomiting  ceased  ; 
food  could  be  taken  into  the  stomach  without  causing  pain  ; the  epigastric 
region  was  soft  and  free  from  pain  ; the  skin  no  longer  retained  its  dryness  ; 
the  natural  appearance  of  the  countenance  returned,  and  the  patient  was  soon 
perfectly  restored  to  health. 

Dr.  Marc  lately  showed  us  a case  resembling  the  preceding  in  several  par- 
ticulars. An  actor  at  one  of  the  Parisian  theatres,  about  40  years  of  age,  had 
had  several  times  symptoms  of  venerea,  gonorrhooa,  chancres*  tumefaction  of 
the  inguinal  glands,  swelling  of  different  parts  of  the  periosteum,  pains  in  the 


28  6 


ANDRAL’S  MEDICAL  CLINIC. 


bones,  cutaneous  pustules  ; lie  had  never  undergone  any  regular  course  of  treat* 
ment.  When  he  consulted  M.  Marc,  he  was  in  the  most  deplorable  state  of 
wasting  ; his  countenance  was  very  pale,  and  expressive  of  suffering  ; hollow 
jaws,  great  emaciation ; such  exhaustion  that  he  could  scarcely  walk  about  his 
room  : he  could  no  longer  go  down  stairs  ; he  had  a small,  dry,  frequent  cough, 
with  hoarseness,  and  slight  pains  in  the  larynx,  respiration  short  and  hurried  ; 
tongue  a little  red  ; loss  of  appetite,  epigastric  pain  ; frequent  vomiting  ; stools 
natural,  acute  and  deep-seated  pain  in  the  limbs  ; painful  swelling  towards  the 
middle  of  the  internal  surface  of  the  tibia,  appearing  to  depend  on  a swelling  of 
the  periosteum. 

From  the  group  of  symptoms  just  enumerated,  this  individual  appeared  to 
labour  under  twofold  chronic  inflammation  of  the  stomach  and  bronchi,  and 
one  might  very  strongly  suspect  in  him  the  existence  of  pulmonary  tubercles 
and  dread  their  development.  However,  we  examined  his  chest  with  M.  Marc, 
and  neither  this  mode  of  examination,  nor  percussion,  revealed  any  organic 
lesion  of  the  respiratory  organs.  The  patient  had  been  for  a long  time  back 
subjected  to  all  the  varieties  of  the  antiphlogistic  treatment  without  any  benefit. 
In  this  state  of  things,  M.  Marc  asked  himself  whether  this  was  not  an  instance 
of  venereal  phthisis  ; and  after  having  considered  the  matter  with  us,  he  com- 
menced the  employment  of  mercurial  frictions ; they  were  continued  for  some 
time  ; sarsaparilla  ptisan  was  given  internally.  By  degrees  his  strength  was 
restored,  his  countenance  assumed  a more  natural  aspect,  and  his  flesh  returned  ; 
the  very  troublesome  symptoms  arising  from  his  lungs  and  stomach  disap- 
peared, and  at  the  end  of  three  months  of  a treatment  in  which  mercury  was 
pushed  far  enough  to  excite  salivation,  this  gentleman’s  health  was  perfectly  re- 
established. 

Whatever  maybe  the  cause  to  which  we  may  be  disposed  to  refer  the  gastric 
symptoms  presented  by  these  two  individuals,  and  also  the  very  serious  symptoms 
of  chest  affection  presented  by  the  second,  from  the  two  facts  now  cited  the  con- 
clusion may  be  safely  and  fairly  drawn,  that  symptoms  similar  to  those  indicating 
an  organic  lesion  of  the  stomach  or  lungs  may  disappear,  during  the  employ- 
ment of  a medicine,  which,  like  mercury,  must  on  the  contrary  exasperate  those 
symptoms,  if  the  organic  lesion  which  the  latter  seemed  to  indicate  really  ex- 
isted. This  lesion  is,  however,  the  common  termination  to  which  every 
affection  tends,  which,  by  its  continuance  in  a tissue,  more  or  less  modifies  its 
nutrition.  Thus  we  are  satisfied  that  the  disturbance  of  digestion,  which  manifests 
itself  after  intense  mental  emotions,  intellectual  fatigue,  or  excesses  in  mastur- 
bation, is  owing  to  the  suspension,  or  rather  to  the  perversion  which  that  portion 
of  the  nervous  system  undergoes,  which  in  the  normal  state  presides  over  the 
act  of  chymefaction.  It  is  not  then  an  inflammation  at  first ; but  it  is  no  less 
true,  that  if  this  perversion  of  the  innervation  is  prolonged,  the  nutrition  of  the 
different  tissues  of  the  stomach  becomes  deranged,  congestions  are  set  up,  and 
what  was  at  first  but  a neurosis,  becomes  changed  into  a serious  organic  lesion. 
Thus  many  cancers  of  the  stomach  may  be  referred  for  their  origin  to  strong 
mental  emotions  ; thus  also,  attacks  of  vomiting,  which  at  their  commence- 
ment were  calmed  by  opiates,  and  then  appeared  to  be  purely  nervous,  subse- 
quently change  character,  and  become  symptomatic  of  real  gastritis.  In  such 
cases  it  does  not  seem  to  us  that  it  is  merely  one  and  the  same  disease,  which 
in  its  various  degrees  assumes  different  shades  in  its  symptoms  and  its  treat- 
ment ; our  opinion  is,  that  there  is  actually  a transformation  of  one  disease  into 
another.  We  think  it  any  thing  but  good  physiology  to  see,  in  every  change 
in  the  functions  of  the  stomach,  nothing  but  a result  of  irritation  varying  merely 
in  degree.  Persons  then  think  of  nothing  but  of  combating  the  inflammation 
by  bloodletting,  forgetting  that  oftentimes  this  inflammation  is  itself  an  effect, 
and  that  by  bloodletting  they  do  not  at  all  come  at  the  cause  which  produces 


DISEASES  OF  THE  ABDOMEN. 


28  7 


it.  It  is  this  cause  which  it  should  be  their  chief  business  to  check,  to  find, 
and  to  combat.  It  was  in  this  way  that  those  physicians  reasoned  who  attended 
the  two  last  patients  whose  cases  we  have  given,  and  they  succeeded.  If  be- 
sides it  is  true  that  ulceration  of  the  skin,  of  the  buccal  and  pharyngeal  mucous 
membrane  are  to  be  referred  to  the  syphilitic  virus*  as  their  cause,  and  that  the 
mercurial  mode  of  treatment  is  successfully  employed  against  them,  we  do  not 
see  why  ulcerations,  or  other  lesions  of  more  deep  seated  parts  of  the  mucous 
membranes,  might  not  also  recognise  the  same  cause,  and  yield  to  the  same 
mode  of  treatment.  Numerous  and  accurate  observations  can  alone  decide  this 
question,  and  for  such  observations  science  still  waits. 


CHAPTER  IV. 

OBSERVATIONS  ON  LEAD-COLIC,  AND  ON  SOME  OTHER  DISEASES  OF  THE 

DIGESTIVE  PASSAGES  WHICH  RESEMBLE  IT  WITH  RESPECT  TO  THEIR 

SYMPTOMS  AND  THE  TREATMENT  SUITABLE  TO  THEM. 

The  history  of  lead-colic  has  been  already  carefully  traced  by  several  writers^ 
nor  would  we  have  spoken  of  it  in  this  part  of  the  work,  had  not  many  points  of 
the  history  of  this  disease  lately  become  an  object  of  discussion,  in  consequence 
of  the  new  medical  doctrines.  What  is  its  nature  1 In  what  state  is  the  diges- 
tive tube  found  in  those  who  die  ? What  sort  of  lesion  does  it  occasion,  con- 
secutively, in  the  functions,  or  in  the  organisation  of  the  nervous  system  ? Is 
the  disturbance  of  this  system  always  consecutive  on  the  lesion  of  the  digestive 
passages  ? is  it  not  sometimes  primary  ? What  is  the  best  treatment  to  be  em- 
ployed in  this  disease  ? Are  the  therapeutic  means,  which  succeed  in  removing 
the  colic  itself,  equally  effectual  in  destroying  the  effects  which  depend  on  the 
alteration  of  the  nervous  centres  ? Does  the  colic  produced  by  the  preparations 
of  copper,  in  which  there  is  diarrhoea,  whilst  there  is  constipation  in  lead- 
colic,  call,  however,  for  the  same  treatment  as  the  latter.  Lastly,  may  not  the 
consideration  of  the  symptoms  of  this  species  of  colic,  and  of  the  treatment 
employed  in  it,  not  only  without  danger,  but  even  with  advantage,  and  the 
consideration  also  of  the  state  in  which  the  digestive  tube  is  found  in  such  cir- 
cumstances, may  it  not,  I say,  contribute  to  throw  some  light  on  the  nature  and 
seat  of  different  abdominal  pains,  which,  appearing  to  reside  in  the  digestive 
passages,  seem,  Tiowever,  to  depend  neither  on  a peritonitis  nor  on  a real  ente- 
ritis ? From  the  fact  that  patients  labouring  under  lead-colic,  bear  with  impu- 
nity strong  doses  of  the  most  violent  drastic  purgatives,  we  must  not  certainly 
conclude,  as  many  persons  do,  that  the  gastro-intestinal  mucous  membrane  pos- 
sesses but  very  little  sensibility ; for  this  membrane  is  then  no  longer  in  its 
healthy  state  ; but  we  may  be  allowed,  at  least,  to  draw  this  consequence,  that 
other  states  of  the  system  may  also  present  themselves  where  the  natural  sen- 
sibility of  the  intestinal  mucous  membrane  being  below  its  normal  state,  stimu- 
lants of  a more  or  less  energetic  nature  may  be  brought  in  contact  with  it  with 
impunity ; this  same  circumstance  takes  place  normally  in  certain  individuals, 
as  may  be  seen  in  several  of  the  cases  already  cited  in  the  preceding  part  of 
this  work.  We  trust  the  following  observations  will  serve  to  clear  up  some  of 
the  questions  now  started. 

* We  entreat  the  reader  to  observe  that  the  success  of  the  mercurial  treatment  in  such  cases 
is  attested  by  too  large  a number  of  facts  to  be  called  in  question,  even  when  the  existence  of 
the  syphilitic  virus  should  not  be  admitted. 


2SS 


ANDRAL’S  MEDICAL  CLINIC. 


FIRST  ARTICLE. 

STATE  OF  THE  DIGESTIVE  TUBE  IN  PERSONS  WHO  DIED  WHILST  LABOUR- 
ING UNDER  LEAD-COLIC. 

Several  writers  have  stated  that,  in  patients  who  die  during  the  existence 
of  lead-colic,  the  intestines  are  found  contracted,  and  their  calibre  perceptibly 
diminished.  Desbois  de  Rochefort  says  that  in  two  cases  he  found  intestinal 
intus-susceptions.  Many  physicians  now  think  that  lead-colic  is  but  a variety  of 
gastro-enteritis,  and  consequently,  that  post-mortem  examination  should  detect 
in  the  digestive  tube,  traces  of  inflammation,  more  or  less  intense  : up  to  the 
present,  I am  not  aware  that  any  autopsy  has  justified  this  view  of  the  matter. 
But,  even  though  some  cases  might  be  cited  in  which  an  intestinal  inflamma- 
tion was  found,  still  that  would  not  decide  the  question  ; for  we  might  be  war- 
ranted in  considering  this  inflammation  merely  as  a simple  complication  of 
lead-colic,  if  other  cases  were  brought  to  show,  that  in  persons  who  also  died 
during  the  course  of  this  colic,  the  digestive  tube  presented  no  species  of  appre- 
ciable alteration.  Now,  this  absence  of  lesion  is  proved  by  the  facts  which  we 
are  now  going  to  cite.  — Out  of  more  than  five  hundred  persons  affected  with 
lead-colic,  who,  during  the  space  of  eight  years,  were  treated  at  the  Charite,  in 
the  wards  of  M.  Lerminier,  only  five  died,  whilst  they  were  placed  under  the  ordi- 
nary treatment  of  colic,  and  again,  of  these  five  individuals,  there  were  two  at 
least,  who  died  with  symptoms  totally  unconnected  with  lead-colic. 

Case  1. — Colic — Sudden  death  occasioned  by  a rupture  of  the  aorta.  No  lesion  found  in  the 

digestive  tube. 

A house-painter,  thirty-three  years  of  age,  had  been  already  treated  twice  for 
colic  at  the  Charite,  when  he  entered  it  for  the  third  time  in  the  commencement 
of  the  summer.  He  presented  all  the  symptoms  of  lead-colic  ; acute  abdominal 
pains,  which  were  neither  increased  nor  diminished  by  pressure  ; the  abdominal 
parietes  retracted  ; vomiting,  obstinate  constipation,  state  of  tongue  natural,  pain 
in  the  limbs,  apyrexia.  Since  the  last  fifteen  days  he  had  had  no  stool,  and 
since  the  last  five  days  only,  the  abdominal  pains  began  to  appear.  The 
patient  had  taken  some  castor-oil  when  at  home,  which  had  not  overcome  the 
constipation.  Immediately  after  his  admission  the  ordinary  treatment  of  the 
Charite  was  commenced  ; he  was  as  yet  but  on  the  third  day  of  this  treatment, 
and  was  but  very  slightly  relieved,  when  he  all  at  once  complained  of  an  un- 
usual pain  towards  the  precordial  region,  and  in  the  course  of  a few  minutes  he 
expired.  — The  post-mortem  showed  that  the  cause  of  this  sudden  death  was  a 
complete  laceration,  a real  perforation  of  the  portion  of  the  aorta  contained  in 
the  pericardium  ; this  sac  was  filled  with  a coagulum  of  black  blood.  In  con- 
sequence of  the  disease  for  which  this  person  had  been  admitted,  we  examined 
his  digestive  tube  with  the  greatest  care  ; it  was  the  first  time  we  had  an  oppor- 
tunity of  opening  the  body  of  va  patient  who  died  during  the  existence  of  lead- 
colic. 

What  struck  ns  at  first  was  the  total  absence  of  contraction  of  the  digestive 
tube  ; the  convolutions  of  the  small  intestines,  as  well  as  the  different  portions 
of  the  colon, were,  on  the  contrary,  rather  dilated.  The  peritoneum  was  healthy. 
The  inner  surface  was  whitish  ; its  mucous  membrane  of  ordinary  thickness 
and  consistence  ; it  was  covered  with  a considerable  quantity  of  thready  mucus. 
The  duodenum  presented  its  cryptae  developed  as  usual  ; it  also  was  white  and 
healthy.  We  merely  found  in  thejejenum  and  ileum  some  few  points  where 
there  existed  a submucous  vascular  arborisation.  The  inner  surface  of  the 
caecum,  colon  and  rectum  was  white,  and  the  mucous  membrane  presented  no 


DISEASES  OF  THE  ABDOMEN. 


2S9 


alteration  with  respect  to  thickness  and  consistence.  The  large  intestine  con- 
tained but  a small  quantity  of  hard  faeces.  This  case  is  certainly  one  of  those 
wherein  we  found  the  digestive  tube  as  free  as  possible  from  any  trace  of  inflam- 
mation ; however,  the  patient  died  of  rupture  of  the  aorta,  whilst  his  colic  was 
still  very  severe  ; the  intestinal  mucous  membrane  had  not  even  been  permanently 
reddened  by  the  drastic  purges.  Let  it  not  be  said  that,  in  this  case,  the  gastro- 
intestinal mucous  membrane  was  pale  in  consequence  of  the  hemorrhage  which 
occurred  towards  the  termination  of  life  : for  this  hemorrhage  was  very  slight ; 
there  was  not  half  a pound  of  blood  effuse'd  into  the  pericardium.* 

Case  2. — Colic — Death  by  cerebral  hemorrhage — Digestive  tube  healthy. 

A middle-aged  man,  engaged  in  the  manufacture  of  white  lead,  had  been  for 
some  days  complaining  of  acute  abdominal  pain  with  all  the  symptoms  of  lead- 
colic,  when  he  entered  the  Charite.  On  the  following  day  he  had  an  attack  of 
apoplexy,  of  which  he  died  at  the  end  of  two  days  ; drastric  lavements  had  been 
employed  without  any  evacuation  being  occasioned  by  them.  The  autopsy 
detected  considerable  effusion  of  blood  like  currant  jelly  in  the  substance  of  the 
right  cerebral  hemisphere,  external  to  and  on  a level  with  the  corpus  striatum 
and  optic  thalamus  of  this  side.  The  stomach  presented  some  slight  sub-mucous 
injection  towards  the  great  cul-de-sac;  it  was  white  everywhere  else.  The 
small  intestine  presented  some  little  sub-mucous  injection,  principally  residing 
in  the  veins  of  a moderate  calibre  ; the  mucous  membrane  itself  was  everywhere 
pale  ; so  was  that  of  the  large  intestine  also.  The  calibre  of  the  digestive  tube 
was  neither  diminished  nor  increased.  Unless  it  be  said  that  the-,cerebral  con- 
gestion had  acted  as  a revulsive  in  this  individual,  and  thus  caused  the  intestinal 
irritation  to  disappear,  it  must  be  admitted  in  this  case  also,  that  the  lead-colic 

did  not  depend  on  a gastro-intestinal  inflammation. 

% 

Case  3. — Colic. — Alarming  nervous  symptoms — Slight  redness  of  the  transverse  colon  over  a 

small  portion  of  its  extent. 

A man,  about  fifty  years  of  age,  a plumber,  entered  the  Charite  with  a violent 
attack  of  colic,  which  he  had  been  labouring  under  for  the  last  few  days.  We 
commenced  with  the  ordinary  treatment.  On  the  third  day,  being  somewhat 
relieved,  though  still  suffering  severely,  he  was  seized  suddenly  with  very  severe 
nervous  symptoms  which  shall  be  described  presently,  and  in  two  hours  after 
he  died. 

On  opening  the  body,  the  gastric  mucous  membrane  was  found  in  the  normal 
state.  All  the  small  intestine  was  found  to  be  white,  except  in  several  detached 
points,  which  taken  together  might  equal  a foot  in  extent ; here  we  observed 
considerable  injection,  not  sufficient,  however,  to  destroy  the  transparency  of 
the  intestinal  parietes.  The  large  intestine  was  white  and  healthy,  except  to 
the  extent  of  three  or  four  inches  towards  the  end  of  the  transverse  colon,  where 
some  redness  was  observed. 

The  digestive  tube  here  presented  some  slight  alterations  which  did  not  exist 
in  the  preceding  cases  ; but  surely  no  one  will  pretend  to  refer  the  symptoms 
observed  during  life  to  them,  there  being  very  few  bodies  in  whose  intestines 
similar  lesions  are  not  found  occasionally. 

Case  4. — Colic — Epilepsy — Sudden  death — Slight  redness  of  a small  portion  of  the  transverse 
colon  : black  colouring  of  the  follicles. 

A painter,  about  thirty-eight  years  old,  entered  the  Charite  in  consequence 

* It  may  be  laid  down  as  a general  principle,  that  the  very  sudden  death  which  follows  rup- 
ture of  the  heart  or  large  vessels  still  contained  within  the  pericardium,  is  not  owing  to  the 
great  quantity  of  the  blood  effused  into  this  membranous  sac. 

25 


290 


AN  DUAL’S  MEDICAL  CLINIC. 


of  lead-colic.  The  day  after  his  admission  he  had  an  attack  of  epilepsy.  On 
the  folio  wing  days  the  abdominal  pains  continued,  but  were  not  severe;  the 
ordinary  treatment  was  resorted  to.  Ten  days  after  his  admission,  the  colic 
still  existing,  this  patient  died  suddenly.  On  opening  the  body  nothing  was 
found  in  the  stomach  but  a slate  colouring  of  the  mucous  membrane  towards  the 
pylorus,  to  an  extent  equal  to  about  two  five  franc  pieces.  The  small  intestine 
was  white,  except  towards  the  summit  of  some  valves,  where  slight  redness  was 
observed,  which  consisted  merely  in  a vascular  arborisation,  not  at  all  considera- 
ble, when  these  valvulae  were  unfolded.  Immediately  above  the  caecum  we  found 
a large  Peyer’s  patch  with  black  points  ; on  the  caecum  also  some  detached  fol- 
licles were  found  with  a black  point  at  their  centre.  Nothing  worth  notice  in 
the  rest  of  the  large  intestine  ; it  was  white,  except  towards  the  termination  of 
the  transverse  colon,  where  a reddish  band  was  observed  about  one  inch  in 
breadth,  and  from  two  to  three  in  length.  Where  this  band  was,  the  mucous 
membrane  lost  a little  of  its  consistence. 

The  unusual  colour  observed  in  a portion  of  the  stomach,  the  black  points  on 
the  follicles  of  the  termination  of  the  small  intestine  and  of  the  caecum,  are 
chronic  states  which  cannot  be  considered  as  having  any  connexion  with  the 
symptoms  presented  by  the  patient  during  his  stay  in  the  hospital.  The  slight 
colouring  of  some  of  the  valves  of  the  jejunum,  the  red  band  found  in  the  colon, 
appear  to  us  to  be  lesions  too  inconsiderable  on  the  one  hand,  and  on  the  other 
hand  are  found  too  often  under  every  possible  state  of  things,  to  allow  us  to 
refer  to  them  the  special  symptoms  which  characterise  lead-colic.  We  shall 
recur  again  to  the  state  in  which  the  nervous  system  was  found  in  this  patient. 

Case  5. — Colic — Paralysis  of  the  upper  extremities — Suddenly  symptoms  of  asphyxia  and 
death — Some  redness  in  different  parts  of  the  intestine. 

A plumber,  about  fifty  years  of  age,  who  had  had  colic  several  times,  was  la- 
bouring under  it  for  the  last  three  weeks  when  he  entered  the  Charite.  The 
pains  were  not  violent,  but  continual,  and  from  time  to  time  they  became  very 
acute.  There  was  obstinate  constipation.  Further,  this  individual  had  com- 
plete paralysis,  affecting  the  motion  of  the  upper  extremities.  The  usual  treat- 
ment was  commenced.  On  the  fourth  day  there  was  a tracheal  rale  ; a state  of 
asphyxia,  and  death. 

Here  also  for  the  present  we  shall  speak  only  of  the  state  of  the  digestive  tube. 
The  stomach  was  distended  by  a moderate  quantity  of  liquid.  Towards  the  great 
cul-de-sac,  a portion  of  its  mucous  membrane  about  the  size  of  the  palm  of  the 
hand  was  found  softened.  Over  this  same  extent  it  was  white,  except  in  two 
points,  where  two  reddish  patches  existed,  one  of  which  was  about  the  size  ot 
a twenty  sous  piece,  and  the  other  that  of  a forty  sous  piece.  Every  where 
else  the  mucous  membrane  was  white,  and  of  the  natural  consistence  and  thick- 
ness. The  small  and  large  intestines  were  rather  dilated  thjan  contracted.  The 
small  intestine  presented  here  and  there  slight  sub-mucous  injection  (as  was  to 
be  expected  from  the  kind  of  death  of  which  the  patient  died).  The  mucous 
membrane  of  the  caecum  presented  a red  patch  of  the  breadth  of  a piece  of  three 
livres  at  most.  The  end  of  the  large  intestine  was  white  ; we  merely  observed 
some  large  vein.s  passing  beneath  the  mucous  membrane.  We  found  here  no 
other  lesion  worth  remarking,  except  softening  of  a portion  of  the  mucous 
membrane  of  the  stomach  ; but  it  was  not  on  this  softening  that  the  colic  de- 
pended, which,  moreover,  in  this  individual  was  less  violent  than  in  the  pre- 
ceding patients. 

Thus,  then,  in  all  those  who  died  whilst  labouring  under  lead-colic,  and  whose 
bodies  we  had  an  opportunity  of  opening,  not  one  presented  in  the  digestive 
tube,  any  lesions  by  which  we  could  account  for  the  symptoms  of  the  disease. 
To  the  five  facts  nowcited  we  might  add  a sixth,  which  is  contained  in  a me- 


DISEASES  OF  THE  ABDOMEN. 


291 


moir  of  M.  Louis  on  sudden  and  unexpected  deaths.  The  patient,  whose  case 
lie  has  detailed,  died  suddenly,  eight  days  after  he  had  been  attacked  with 
lead-colic. 

Case  6. — Lead-colic  treated  by  the  modified  method  of  the  Charite.  At  the  end  of  a month 
the  appearance  of  nervous  symptoms — Death — Nothing  found  in  the  intestines. 

On  the  28th  of  November,  a man  of  about  forty-six  yeats  of  age,  employed  in 
the  manufactory  of  Clichy,  entered  the  Charite,  where  he  was  placed  in  the  wards 
of  M.  Fouquier.  The  principal  symptoms  presented  by  him  were  the  following : 
pain  in  the  abdomen,  and  more  particularly  along  the  course  of  the  colon,  con- 
stipation, pain  of  head ; the  abdomen  was  not  depressed.  This  person  was 
treated  according  to  the  Charite  method  modified  by  M.  Fouquier,  without  any 
obvious  improvement;  the  colicky  pains  continued  a very  long  time,  he  com- 
plained of  them  almost  every  day. — Such  was  the  state  of  the  patient,  when  on 
the  2d  of  January  he  felt  a little  numbness  and  sense  of  formication  in  the  extre- 
mities. On  the  evening  of  the  5th  he  uttered  several  shrieks,  and  was  seized 
with  convulsions,  which  were  succeeded  by  loss  of  speech  and  motion.  At  the 
v'isit  of  the  next  morning  his  countenance  was  pale,  his  look  was  stupid;  his 
head  was  inclined  to  the  right,  his  intellectual  faculties  were  abolished,  sensi- 
bility was  entirely  destroyed;  the  power  of  motion,  which  was  at  first  abolished, 
was  somewhat  restored;  the  patient  occasionally  carried  his  hand  to  his  mouth, 
and  moved  his  legs  tolerably  well.  (General  bleeding,  sinapisms  to  the  legs, 
laxative  mixture,  etc.)  The  sinapisms  produced  no  effect.  On  the  7th,  the 
eyes  were  entirely  carried  to  the  right,  the  patient  understood  somewhat  better 
the  questions  put  to  him;  the  pulse  was  small;  there  were  convulsive  move- 
ments, and  considerable  gurgling  in  the  throat  and  chest.  (Blisters  to  the  legs.) 
On  the  following  night  he  uttered  some  inarticulate  cries  and  expired. 

Post-mortem. — The  face  indicated  that  death  had  been  painful,  the  features 
were  drawn  and  inclined  to  the  right.  The  abdomen  having  been  opened,  the 
stomach  was  found  to  be  healthy;  nothing  remarkable  in  the  intestines;  only  in 
some  few  places  they  were  contracted  and  slightly  strangulated,  but  without  any 
trace  of  inflammation.  The  external  surface  of  the  brain  was  injected,  its  sub- 
stance a little  more  dense  than  natural ; the  ventricles  contained  no  serum ; spinal 
marrow  was  healthy. 


ARTICLE  II. 

SYMPTOMS  OF  LEAD  COLIC. 

We  shall  not  here  dwell  on  the  ordinary  symptoms  of  this  colic,  as  the  descrip- 
tion of  them  may  be  had  everywhere.  We  shall  merely  notice  the  following 
particularities:  it  is  not  correct  to  say  that  the  abdominal  pain  experienced  by 
persons  labouring  under  lead  colic  is  invariably  diminished  by  pressure,  as  in  a 
great  number  of  cases  this  pain  is  neither  increased  nor  assuaged  by  it ; and 
sometimes  even  pressure  increases  its  severity.  Yet  in  these  different  cases 
the  other  symptoms  of  the  disease  remain  the  same;  and  the  same  treatment 
succeeds.  Neither  is  the  abdomen  uniformly  retracted,  nor  do  the  abdominal 
parietes  appear  always  depressed  towards  the  umbilicus.  It  is  probably  as 
common  to  find  the  abdomen  retain  its  usual  form  and  ordinary  dimensions,  or 
even  become  larger  and  more  developed  than  usual,  which  seems  to  depend  on 
the  distention  of  the  intestines  by  solid  substances  or  gases.  The  most  con- 
stant and  invariable  phenomenon  is  constipation  ; it  precedes  the  colicky  pains, 
and  the  latter  diminish  as  soon  as  alvine  evacuations  commence. 

But  the  digestive  tube  is  not  the  only  organ  affected  in  persons  who  have 


292 


ANDRAL’S  MEDICAL  CLINIC. 


absorbed  the  particles  of  lead.  The  nervous  system  is  frequently  influenced 
by  such  absorption  in  a very  remarkable  manner.  Thence  result,  according  to 
the  idiosyncrasy  of  the  patient,  or  according  to  the  part  of  the  system  more  par- 
ticularly affected,  or  according  to  the  degree  in  which  it  is  affected,  various  phe- 
nomena, which  are  most  frequently  developed  in  the  organs  of  the  life  of  rela- 
tion, though  sometimes  also  in  those  of  the  life  of  nutrition. 

The  most  common  of  these  nervous  disturbances  consist  in  pains  felt  by  the 
patients  in  the  extremities,  and  principally  in  the  arms  ; those  pains  often  pre- 
cede the  colic  ; sometimes  they  constitute  the  only  phenomenon,  and  the  func- 
tions of  the  digestive  tube  are  not  at  all  disturbed  ; whence  we  must  conclude, 
contrary  to  the  opinion  of  some  writers,  that  they  are  not  merely  sympathetic  of 
the  intestinal  affection.  These  pains  are  often  accompanied  by  unusual  weak- 
ness in  the  muscular  action  of  the  part  wherein  they  are  felt,  and  by  degrees  this 
weakness  becomes  changed  into  real  paralysis.  Thus  we  find  exaltation  of  the 
normal  sensibility,  and  diminution  of  motion,  combined  in  this  case.  What 
then  takes  place  in  the  extremities  appear  very  analogous  in  its  nature  to  that 
which  takes  place  in  the  intestines,  where,  at  the  same  time  that  pain  exists,  there 
also  appears  to  be  a diminution  in  the  strength  of  the  normal  contractility  of  the 
muscular  tunic,  as  also  of  the  sensibility  of  the  mucous  membrane,  which  bears 
with  impunity  the  contact  of  the  most  drastic  purgatives. 

The  most  ordinary  paralysis  in  persons  who  handle  lead  is  that  of  the  extensor 
muscles  of  the  hand  ; hence,  in  consequence  of  the  equilibrium  of  muscular 
action  being  destroyed,  there  arises  an  habitual  predominance  in  the  contraction 
of  the  flexor  muscles  of  the  hand,  and  consequently  permanent  flexion  of  the 
wrist,  which  remains  inclined  so  as  to  form  almost  a right  angle  with  the  bones 
of  the  fore-arm.  The  fingers  also  become  flexed  on  the  wrist ; the  different  pha- 
langes are  then  observed  to  be  inclined  one  upon  another. 

This  paralysis  most  usually  comes  on  only  in  persons  who  have  been  a long 
time  employed  in  preparations  of  lead,  and  have  had  colic  several  times.  How- 
ever, we  have  seen  it  come  on  in  some  cases  where  the  patients  had  been  but 
a very  short  time  exposed  to  the  influence  of  lead,  and  where  they  had  never 
had  any  attack  of  colic  previously.  In  some  cases  it  disappears  rather  promptly  ; 
at  other  times  it  does  not  disappear  till  after  a considerable  time  ; whilst  at  other 
times  it  is  altogether  incurable. 

Paralysis  occasioned  by  the  preparations  of  lead,  is  not  always  limited  to  the 
wrists.  We  have  seen  it  affect  the  entire  upper  extremities,  which  became  alto- 
gether deprived  of  motion.  We  had  twice  an  opportunity  of  examining  the 
bodies  of  persons  attacked  with  this  species  of  paralysis.  One  of  these  patients 
had  colic  at  the  same  time  when  he  entered  the  Charite  : this  was  one  of  those 
of  whom  we  had  already  spoken,  in  reference  to  the  digestive  tube.  The  other 
had  had  colic  long  before,  but  no  trace  of  it  remained  at  the  time  he  came  under 
our  inspection.  In  the  former  the  paralysis  commenced  only  some  weeks  be- 
fore, whilst  in  the  latter  it  was  of  several  months  standing.  In  both,  the  upper 
extremities  were  entirely  deprived  of  the  power  of  motion  : when  raised,  they 
fell  back  as  inert  masses  : still  rather  sharp  pains  were  felt  in  them  from  time 
to  time,  and  the  sensibility  of  the  skin  was  still  retained.  In  both,  the  intellects 
were  unimpaired,  and  the  power  of  speech  perfectly  free.  Both  died  also  in 
the  same  way  ; their  respiration  became  suddenly  impeded,  the  tracheal  rale 
set  in,  and  they  died  in  a state  of  asphyxia,  nearly  like  animals  in  which  the 
two  pneumogastric  nerves  were  divided,  when  they  survive  the  operation  for 
some  days,  and  die  of  infarction  of  the  lung. 

From  the  group  of  symptoms  observed  during  life,  it  was  less  in  the  brain  than* 
in  the  spinal  marrow  that  one  should  expect  to  find  any  organic  change.  The 
encephalic  mass,  when  carefully  examined  in  its  several  parts,  presented  nothing 
remarkable.  The  spinal  canal  contained  a small  quantity  of  limpid  serum,  such 


DISEASES  OF  THE  ABDOMEN. 


293 


as  is  found  in  most  bodies.  The  membranes  of  the  spinal  marrow  were  pale  ; 
the  marrow  itself,  examined  from  its  junction  with  the  tuber  annular  to  its  lower 
termination,  presented  no  appreciable  alteration  in  its  colour,  consistence,  or  in 
any  of  its  physical  properties.  The  cervical  plexuses,  as  well  as  the  nervous 
chords  which  pass  from  them,  the  pneumogastric  nerves  from  their  origin  to 
their  termination  in  the  stomach,  were  also  found  exempt  from  all  manner  of 
lesion.  The  lungs  were  simply  engorged.  The  other  organs  of  the  chest  and 
abdomen  were  found  healthy,  except  the  stomach  of  one  of  the  two  patients, 
which  was  softened  in  a small  portion  of  its  extent,  as  we  have  already  stated. 
There  is  no  doubt  but  in  both  these  individuals  some  point  of  the  cerebro-spinal 
axis  was  seriously  changed  ; but  this  change  was  proved  only  by  the  symp- 
toms, and  not  at  all  by  anatomy. 

In  other  individuals,  but  much  more  rarely,  we  have  ascertained  the  exist- 
ence of  complete  or  incomplete  paraplegia,  with  exaltation  of  the  sensibility, 
and  acute  pains  in  the  paralysed  limbs.  In  several,  the  upper  extremities  were 
not  at  all  affected  ; in  others,  there  was  at  the  same  time  greater  or  less  debility 
of  the  upper  extremities. 

Instead  of  paralysis,  we  have  sometimes  observed  in  persons  exposed  to 
the  influence  of  lead  preparations,  convulsive  movements,  and  attacks  of 
an  epileptic  form.  The  following  is  an  instance  of  it,  with  th e post-mortem 
examination. 

Case  7. — Lead-colic — Symptoms  of  epilepsy — Sudden  death — No  appreciable  lesion  on  the 

dead  body. 

A house  painter,  about  38  years  of  age,  had  colic  at  the  time  he  entered  the 
Charite.  On  the  day  after  his  admission  he  had  an  attack  of  epilepsy,  which 
was  prolonged  for  a considerable  time,  and  was  followed  by  a state  resembling 
apoplexy,  which  lasted  from  30  to  40  hours ; whilst  it  lasted  the  patient  ap- 
peared to  be  in  the  last  agony.  However,  these  alarming  symptoms  disap- 
peared, he  recovered  his  intellect  and  power  of  motion,  but  the  mental  faculties 
still  remained  a little  dull.  The  countenance  was  pale  and  expressive  of  dis- 
tress ; the  colicky  pains  continued,  though  not  severe.  Some  days  passed  on 
in  this  way.  One  evening  when  the  patient  was  replacing  himself  in  his  bed, 
which  he  had  quitted  for  an  hour  or  two,  his  features  suddenly  altered,  and  he 
died  unexpectedly.  The  post-mortem  took  place  fourteen  hours  after  death. 
The  membranes  of  the  brain  were  pale : the  encephalon  presented  no  trace  of 
sanguineous  congestion  ; when  sliced  it  scarcely  presented  any  red  points. 
Very  little  serum  in  the  ventricles.  Nothing  remarkable  in  the  remainder  of 
the  nervous  portions  contained  in  the  cranium,  nor  in  the  spinal  marrow  or  its 
nerves  ; neither  was  there  any  thing  remarkable  in  the  thoracic  ganglia  of  the 
great  sympathetic,  in  the  nerves  which  are  sent  off  from  them,  in  the  semilunar 
ganglia,  or  in  the  different  abdominal  plexuses.  Healthy  state  of  the  pulmo- 
nary parenchyma,  as  also  that  of  the  heart  and  its  vessels.  Nothing  remark- 
able in  the  abdomen,  except  the  very  slight  lesions  of  the  digestive  tube 
already  noticed.  Again,  there  are  other  individuals  affected  with  lead-colic, 
whom  we  have  seen  die  unexpectedly,  though  they  had  not  previously  pre- 
sented any  remarkable  nervous  symptom,  and  in  whom  also  the  post-mortem 
examination  did  not  detect  any  appreciable  lesion  in  the  nervous  system. 


ARTICLE  III. 

TREATMENT  OP  THE  EFFECTS  PRODUCED  BY  LEAD  PREPARATIONS. 

Several  eminent  physicians  treat  lead-colic  at  the  present  day  as  Haen 
treated  it  long  since,  by  a method  purely  antiphlogistic.  Unquestionably  seve- 
25* 


294 


ANDRAL’S  MEDICAL  CLINIC. 


ral  patients  treated  in  the  ordinary  way  recover  perfectly  well ; but  we  think  it 
right  to  remark  with  respect  to  this  matter,  that  every  time  the  colic  is  assuaged 
the  patients  are  free  from  it  spontaneously  at  the  end  of  a longer  or  shorter  time, 
provided  they  cease  to  handle  lead.  It  is  not  our  object  to  consider  here  the 
results  of  such  a practice,  we  merely  state  what  we  have  seen ; for  we  are  not 
drawing  up  a treatise  on  pathology,  we  are  merely  collecting  materials.  Now, 
from  five  hundred  cases  newly  treated  in  the  wards  of  M.  Lerminier,  labouring 
under  affections  produced  by  lead,  we  have  no  hesitation  in  drawing  the  four 
following  conclusions  with  respect  to  the  treatment  of  these  diseases  : — 

1st.  Lead-colic,  treated  by  bloodletting  and  emollient  drinks,  has  in  general 
a much  longer  duration  than  colic  treated  by  the  method  called  that  of  la 
Charite. 

2dly.  Many  colics  which  have  resisted  the  antiphlogistic  treatment,  yield 
promptly  to  that  of  la^Charite. 

3dly.  We  never  have  seen  the  latter  treatment  fail  in  removing  colic,  some- 
times only  it  must  be  recommenced  three  or  four  times  consecutively  in  order 
that  the  cure  may  be  complete.  In  other  patients  all  the  symptoms  cease  the 
moment  that  evacuations  upwards  and  downwards  have  been  procured. 

4thly.  The  treatment  of  la  Charite,  when  conducted  with  prudence  and  ad- 
ministered at  the  proper  time,  we  never  found  to  occasion  any  species  of  unplea- 
sant consequence : it  is  certainly  very  remarkable  that  such  powerful  drastics 
can  be  brought  in  contact  with  the  intestinal  mucous  membrane  without  inflam- 
ing it,  without  lighting  up  fever,  without  modifying  the  state  of  the  tongue,  or 
producing  disturbance  of  any  kind  ; but  it  must  not  be  forgotten  that  the  diges- 
tive tube  is  then  placed  in  a very  peculiar  condition.  Do  we  not  see  in  the 
same  manner  certain  therapeutic  agents  in  certain  nervous  diseases  no  longer 
retain  their  usual  mode  of  action  ? Thus,  in  tetanus,  enormous  doses  of  opium 
may  be  administered  with  impunity  ; in  apoplexy  too  it  often  happens  that  tartar 
emetic  no  longer  produces  vomiting,  nor  do  the  most  active  lavements  procure 
any  al vine  evacuation. 

Workmen  very  often  enter  the  Charite  who,  labouring  for  some  time  under 
lead-colic,  have  had  leeches  applied  in  great  numbers  over  their  abdomen,  have 
taken  baths,  and  have  been  put  on  milk  diet.  Some  of  these  are  relieved,  but 
not  completely  cured  : the  constipation  remains,  abdominal  pains,  more  or  less 
severe,  continue  to  be  felt,  etc.  When  they  enter  the  Charite  in  this  state  they 
are  soon  cured  under  the  influence  of  the  drastic  mode  of  treatment.  We  have 
seen  several  other  patients  who  had  not  even  derived  the  slightest  relief  from 
the  employment  of  antiphlogistics,  and  whom  the  Charite  treatment  cured 
promptly  and  completely. 

No  doubt  can  be  raised  in  these  cases  with  respect  to  the  real  efficacy  of  the 
therapeutic  method,  its  effects  are  too  well  marked.  Observe  and  interrogate 
the  patients ; they  have  scarcely  begun  to  have  very  copious  evacuations  up 
and  down,  when  the  intolerable  pains  which  they  felt  cease  as  if  by  enchantment. 
Their  countenance  which  became  seriously  changed,  all  at  once  reassumes  a 
natural  appearance  ; they  congratulate  themselves  on  their  prompt  recovery,  and 
those  who,  having  had  colic  more  than  once,  were  already  cured  of  it  by  the 
Charite  treatment,  solicit  it  earnestly  when  they  are  again  attacked,  and  feel  no 
doubt  of  its  success. 

When  there  is  fever,  and  when  pressure  on  the  abdomen  perceptibly  increases 
the  pain,  must  we  also  employ  the  ordinary  treatment?  Our  observation  on 
this  point  is  as  follows  : in  several  individuals  the  treatment,  having  been 
commenced  notwithstanding  these  unusual  symptoms,  was  of  necessity  discon- 
tinued, because  the  state  of  the  patients  became  worse  ; but  at  other  times  this 
treatment,  employed  under  similar  circumstances,  succeeded  notwithstanding. 
According  as  evacuations  were  procured,  the  pulse  returned  to  its  jyitural 


DISEASES  OF  THE  ABDOMEN. 


295 


rhythm,  the  heat  of  skin  was  diminished,  and  the  pains  disappeared.  In  this 
second  case  is  there  but  the  mask  of  inflammation,  whilst  it  really  existed  in  the 
first  ?* 

Do  the  different  nervous  symptoms  which  accompany  or  follow  lead-colic, 
and  which  may  also  exist  without  it,  yield  to  the  same  mode  of  treatment  a3 
this  colic  itself?  The  certainty  of  the  success  of  this  treatment  is  here  much 
less.  We  think,  however,  that  in  such  cases  we  should  try  it  at  first.  We 
have  in  fact  seen  its  employment  completely  remove  either  the  pains  of  the  limbs 
or  their  paralyses,  or  several  other  nervous  phenomena  already  noticed. 

W e very  recently  met  the  case  of  a house  painter,  who,  having  never  had  colic, 
felt  for  nearly  the  last  five  months  in  the  membranes  of  the  head  acute  pains, 
which  were  at  first  considered  as  rheumatic,  and  ineffectually  treated  by  bleed- 
ing, and  both  simple  and  sulphureous  vapour  baths.  He  entered  the  Charite, 
and  was  put  under  the  ordinary  treatment  of  lead-colic,  and  went  out  cured. 
With  respect  to  the  paralysis  it  must  be  still  recent  and  incomplete,  in  order  that 
it  may  disappear  under  the  influence  of  the  ordinary  treatment  of  colic.  If  the 
case  be  otherwise  it  resists,  and  it  then  becomes  necessary  to  employ  medicines 
whose  direct  effect  is  to  excite  muscular  contractility.  For  this  purpose  we  have 
seen  blisters  applied  to  different  points  of  the  arms,  and  in  the  vicinity  of  the 
brachial  plexus  with  variable  success,  divers  frictions  also,  and  stimulating 
douches,  the  different  preparations  of  the  nux  vomica,  either  its  extract  or  strych- 
nine, or  instead  of  the  latter,  another  vegetable  alkali,  brucine,  which,  having  a 
similar  mode  of  action,  may  be  more  easily  managed  by  reason  of  its  being 
much  less  energetic. f The  following  facts  will  give  an  idea  of  the  mode  of 
action  of  these  two  alkalies,  and  of  their  influence  on  the  paralysis  produced  by 
lead  preparations  ; we  shall  add  to  them,  for  the  purpose  of  comparison,  some 
other  cases  wherein  these  same  alkalies  were  employed  in  the  treatment  of  other 
species  of  paralysis. 

A.  — EMPLOYMENT  OF  STRYCHNINE. 

The  strychnine  given  to  the  patients  who  form  the  subject  of  the  following 
cases  was  the  purest  possible ; it  was  entirely  deprived  of  brucine,  with  which 
it  continued  mixed  in  the  first  preparations  of  it  by  Mr.  Pelletier.  It  was  given 
in  the  form  of  pills,  some  containing  only  one-twelfth  of  a grain  of  the  alkali,  and 
others  one-sixth. 

1.  A house  painter,  who  had  had  colic  several  times,  entered  the  hospital 
having  entirely  lost  the  power  of  motion  in  both  hands,  which  remained  habitu- 
ally flexed  on  the  anterior  surface  of  the  fore-arm.  This  paralysis  commenced 
about  a month  before;  it  had  been  treated  without  effect  by  stimulating  frictions 
applied  to  the  fore-arm.  This  individual  took  two  pills,  containing  one-twelftb 
of  a grain  each,  one  in  the  morning,  and  one  in  the  evening.  He  felt,  to  use  his 
own  terms,  a sort  of  painful  fremissement  along  the  extensor  muscles  of  the 
hands.  On  the  three  following  days  the  same  dose  was  given,  and  with  the 
same  effects.  On  the  fifth,  sixth,  and  seventh  day,  four  pills  were  given,  two 
in  the  morning  and  two  at  night : slight  shocks  of  the  limbs  ; spasmodic  con- 
traction of  the  extensors  of  the  fingers,  during  which  there  was  forcible  retro- 
version of  the  fingers  towards  the  back  of  the  hand  ; the  paralysis  appeared  to 
lessen.  Pills  were  then  given  to  the  patient,  containing  one-sixth  of  a grain  ; 
one  at  first,  then  four  after  the  lapse  of  eight  days.  During  this  time  he  felt 

* We  have  lately  employed  croton  oil  at  the  Pitie  in  some  cases  of  lead  colic;  speedy  relief 
was  the  result  of  it,  and  a complete  cure  was  promptly  effected. 

"f  I have  shown  elsewhere  ( Journal  de  Pliysiologie  Experimental , t.  iii.,  and  Annales  du 
Cercle  Medical,  t.  iii.),  that  six  grains  of  pure  brucine  are  necessary  to  produce  the  effects  of 
one  grain  of  impure  strychnine,  and  of  a quarter  of  a grain  of  pure  strychnine. 


296 


ANDllAL’S  MEDICAL  CLINIC. 


some  violent  shocks.  He  soon  left  the  hospital,  complaining  of  nothing  but  a 
little  weakness  in  the  hands. 

In  this  individual  the  dose  of  strychnine  could  not  have  been  raised  without 
danger  beyond  two-thirds  of  a grain  per  day. 

2.  Another  painter  was  affected  with  the  same  disease  as  the  preceding,  and 
for  nearly  the  same  length  of  time.  One  single  pill  containing  one-twelfth  of  a 
grain  occasioned  a slight  trismus,  and  the  commencement  of  tetanic  rigidity  in  the 
muscles  of  the  nucha,  abdomen,  and  extremities.  On  the  following  day  he  took 
another  pill,  and  being  now  somewhat  accustomed  to  it,  he  experienced  but  some 
few  spasmodic  contractions  in  the  extremities.  After  the  lapse  of  six  days,  two 
pills  were  given,  one  in  the  morning,  and  one  at  night ; there  were  violent  con- 
tractions of  both  arms.  The  strychnine  was  continued  at  this  dose  for  about 
fifteen  days,  at  the  end  of  which  time  the  paralysis  was  removed. 

3.  A German,  of  a strong  constitution,  and  affected  for  a long  time  with  para- 
lysis of  the  extensors  of  both  hands,  arising  from  the  influence  of  lead,  took  a 
pill  containing  about  one-twelfth  of  a grain,  without  feeling  any  effect  from  it: 
three  pills  were  then  given  to  him  with  impunity.  On  taking  the  dose  of  one- 
third  of  a grain,  he  began  to  experience  some  shocks  ; they  soon  ventured  to 
give  him  a little  more  than  one  grain  of  strychnine.  On  taking  this  dose,  the 
contractions  became  so  strong,  as  to  induce  the  necessity  of  reducing  it  to  a 
single  grain.  This  person  did  not  experience  any  relief. 

On  comparing  this  case  and  the  preceding,  one  may  see  how  the  action  of 
strychnine  may  vary,  in  consequence  of  the  varying  susceptibility  of  different 
individuals. 

4.  A man  wTho  was  in  the  habit  of  handling  white  lead  had  the  same  kind  of 
paralysis  as  the  preceding.  A pill  containing  one-twelfth  of  a grain,  occasioned 
rather  violent  trismus  in  him.  On  the  next  day  another  pill  was  given  to  him, 
and  this  time,  as  in  the  subject  of  the  second  case,  he  felt  no  effects  from  it. 
Two  pills  produced  rather  violent  shocks  in  the  limbs.  In  a little  time  the 
dose  of  strychnine  was  raised  to  two-thirds  of  a grain  ; but  that  dose  could  not 
be  increased,  in  consequence  of  the  tetanic  symptoms  which  then  manifested 
themselves.  When  the  patient  left  the  hospital,  he  was  less  paralysed. 

5.  In  another  individual  paralysed  like  the  preceding,  the  dose  of  strychnine 
was  increased  in  twelve  days  to  a grain  ; he  had  but  some  slight  contractions. 
The  dose  was  still  increased;  from  that  time  there  was  a closing  of  the  jaws, 
and  a retroversion  of  the  head.  The  patient  became  alarmed  at  this,  and  would 
take  no  more  of  the  pills.  He  left  the  hospital  without  being  relieved. 

6.  A person  entered  the  hospital  affected  with  incomplete  paraplegia,  which 
had  been  treated  ineffectually  by  blisters,  moxas,  and  cauteries,  applied  to  the 
lumbar  region  ; no  deviation  whatever  of  the  spinal  column.  A pill  containing 
one-twelfth  of  a grain  produced  no  effect,  two  pills  occasioned  slight  shocks  of 
the  lower  extremities  ; the  dose  was  raised  to  four  every  day  (an  entire  grain). 
On  taking  this  dose  the  patient  felt  rather  acute  pains  in  the  lumbar  region  ; 
there  was  at  the  same  time  rigidity  of  the  lower  extremities  only ; the  paraple- 
gia was  perceptibly  increased,  the  strychnine  was  stopped. 

In  this  case  the  paraplegia  was  probably  the  result  of  a lesion  of  the  spinal 
marrow,  which  the  strychnine  appeared  to  aggravate. 

7.  An  old  man  had  been  affected  for  a long  time  with  complete  paraplegia  ; 
he  took  three  pills  containing  one-twelfth  of  a grain  each,  without  feeling  any 
effect  from  them.  Four  pills  (one-third  of  a grain)  produced  slight  contractions 
in  the  four  extremities.  No  more  of  them  were  given. 

8.  A man  had  remained  hemiplegic  after  an  old  attack  of  apoplexy  ; a pill  of 
one-twelfth  of  a grain  was  sufficient  to  occasion  intense  tetanic  rigidity  of  the 
paralysed  limbs.  On  the  following  days  this  person,  though  the  strychnine 
was  not  continued,  experienced  violent  headaches  on  the  side  opposite  the 


DISEASES  OF  THE  ABDOMEN. 


297 


hemiplegia  ; his  intellects  became  dull,  the  hemiplegia  increased ; in  a word, 
he  presented  several  of  the  symptoms  which  characterise  softening  of  the  brain. 
Did  the  strychnine  produce  in  this  case  commencing  inflammation  around  the 
old  apoplectic  focus  {foyer)  ? 

B.  II.  — EMPLOYMENT  OF  BRUCINE. 

The  brucine  pills  given  to  the  patients  who  form  the  subjects  of  the  following 
cases,  contained  each  half  a grain  of  this  alkali.  From  the  experiments  made 
on  animals,  we  were  satisfied  that  no  injurious  consequences  would  follow  from 
this  dose. 

1 . A mixer  of  colours  had  paralysis  of  the  hands  for  about  the  last  two  months ; 
he  took  a pill  without  feeling  any  effect  from  it,  two  pills  produced  slight 
shocks  in  the  arms,  four  pills  occasioned  rather  violent  contractions.  He  went 
out  cured. 

2.  Another  mixer  of  colours,  who  was  also  paralytic,  took  as  much  as  four 
grains  of  brucine  without  any  sensible  effect;  in  the  dose  of  four  grains  and  a 
half,  he  experienced  a kind  of  troublesome  formication  in  the  arms  ; in  the  dose 
of  five  grains,  he  felt  some  shocks  of  considerable  violence,  without  any  bad  con- 
sequences. The  paralysis  was  considerably  diminished. 

3.  A house  painter,  who  had  paralysis  of  the  hands,  did  not  begin  to  feel  any 
shocks  till  he  took  the  dose  of  two  grains.  Three  grains  occasioned  consider* 
able  trismus.  The  patient  was  but  slightly  improved. 

4.  A man  engaged  in  the  handling  of  lead,  and  paralysed  as  the  preceding, 
experienced  tetanic  rigidity  of  the  four  extremities,  after  having  taken  three 
grains  and  a half  of  brucine.  He  was  not  relieved. 

5.  A paraplegic  patient,  after  having  taken  only  two  grains  of  brucine,  felt  an 
acute  pain  in  the  sole  of  the  feet,  his  lower  extremities  also  became  the  seat  of 
violent  contractions.  His  state  was  not  improved. 

- From  these  cases  I think  we  may  deduce  the  following  corollaries  : 

1st.  Pure  strychnine  acts  on  man,  as  the  extract  of  nux  vomica,  but  with 
much  greater  intensity. 

2d.  The  action  of  strychnine  is  so  energetic  that  the  greatest  precautions  are 
necessary  to  be  observed  in  its  employment.  Its  effects  also  vary  in  a very 
remarkable  manner,  according  to  the  susceptibility  of  the  individuals.  Thus, 
in  one,  one-twelfth  of  a grain  is  sufficient  to  occasion  serious  consequences  (2), 
whilst  in  another  the  dose  of  strychnine  may  be  increased  almost  with  impunity 
to  a little  more  than  a grain  (3). 

3d.  Brucine  acts  on  man  as  on  animals.  Much  less  energetic  than  strych- 
nine, since  we  may  commence  giving  it  with  impunity  in  the  dose  of  half  a 
grain,  it  may  be  substituted  with  advantage,  as  a medicine,  for  the  alkali  of  nux 
vomica. 

4th.  When  considered  with  respect  to  their  therapeutical  properties,  strych- 
nine and  brucine  are  found  to  be  more  or  less  effectual,  according  to  the  species 
of  paralysis  treated  with  them.  When  employed  in  cases  wherein  the  paralysis 
is  connected  with  an  inflammatory  state  of  the  brain,  or  of  the  spinal  marrow, 
they  will  in  all  probability  aggravate  all  the  symptoms.  In  persons  who  have 
remained  hemiplegic  after  cerebral  hemorrhage,  the  employment  of  these  alkalies 
is  most  frequently  unavailing  ; there  is  even  some  reason  to  dread  that  they  may 
produce  an  inflammation  of  the  cerebral  substance  around  the  apoplectic  focus  (8). 
But  there  are  cases  where,  as  if  by  a sort  of  habit,  the  paralysis  seems  to  con- 
tinue even  after  the  absorption  of  the  effusion  ; it  may  then  yield  to  the  alkalies 
of  nux  vomica  and  false  angustura.  In  a word,  these  same  alkalies  appear  to 
be  principally  efficacious  against  those  palsies,  whose  cause  does  not  seem  to 
reside  in  an  inflammatory  lesion  of  the  nervous  centres  ; such,  particularly,  is 


298 


ANDRAL’S  MEDICAL  CLINIC. 


that  species  of  paralysis,  to  which  persons  engaged  in  lead  manipulations  are  so 
frequently  subject.  The  preceding  cases  attest  the  efficacy  of  strychnine  or 
brucine  in  this  species  of  paralysis  : of  nine  individuals  who  were  attacked,  six 
were  cured,  or  at  least  relieved.  I might  here  cite  other  cases  of  paralysis  of 
the  same  kind,  which  also  yielded  to  the  alkaline  extract  of  nux  vomica. 


ARTICLE  IV. 

NATURE  OF  LEAD-COLIC. 

Is  this  colic  the  result  of  gastro-intestinal  inflammation?  We  can  now 
answer  this  question  in  the  negative.  That  would  certainly  be  an  extraordinary 
gastro-enterite  of  which  no  traces  could  be  found  on  post-mortem  examination  ; 
which,  sufficiently  severe  to  produce  the  most  excruciating  pain,  should  never 
excite  fever,  and  which  should  be  always  cured  with  certainty  by  those  medi- 
cines which  were  peculiarly  calculated  to  exasperate  this  gastro-enterite,  if  it 
really  existed.  If  there  be  any  fact  in  medicine  of  which  we  are  fully  con- 
vinced, it  is  that  lead-colic  is  not  an  inflammation.  If  we  direct  our  attention 
to  the  different  nervous  symptoms  which  complicate  it,  and  which  may  also 
exist  without  it,  we  shall  be  disposed  to  think  that  the  symptoms  which  become 
developed  on  the  part  of  the  digestive  passages,  in  persons  exposed  to  the 
influence  of  lead  preparations,  are  also  the  result  of  the  disturbance  occasioned 
by  the  latter  in  the  functions  of  that  part  of  the  nervous  centres  which  presides 
principally  over  the  digestive  tube.  Lead-colic  is,  then,  in  our  opinion,  a neu- 
rosis, in  which  the  spinal  marrow  and  the  abdominal  plexuses  of  the  great 
sympathetic  appear  to  be  the  peculiar  seat  of  lesion.  The  constipation 
seems  to  depend  either  on  the  abolition  of  the  contractile  motion  of  the  intes- 
tines, or  on  the  suspension  of  the  secretion  of  the  intestinal  mucus. 


ARTICLE  V. 

OBSERVATIONS  ON  CERTAIN  MORBID  STATES,  WHICH,  BY  THEIR  SYMPTOMS 
AND  THEIR  TREATMENT,  BEAR  MORE  OR  LESS  RESEMBLANCE,  TO  THE 
PHENOMENA  OCCASIONED  BY  THE  PREPARATIONS  OF  LEAD. 

The  symptoms  of  lead-colic  sometimes  manifest  themselves  in  persons  who 
were  never  exposed  to  the  influence  of  any  preparation  of  lead  ; it  seems  then, 
that  the  modification  made  by  the  action  of  lead  on  the  nervous  system  may  be 
produced  spontaneously  ; from  whence  the  same  phenomena  will  result,  which 
will  yield  to  the  same  treatment,  more  or  less  modified.  On  this  point,  we 
shall  cite  the  following  fact  which  we  selected  out  of  several  others  resembling 
it  at  the  Charite. 

Case  8. — Abdominal  pains  simulating  those  of  lead-colic — Repeated  employment  of  castor- 

oil — Cure. 

An  individual,  thirty-eight  years  of  age,  of  a strong  constitution,  had  not  been 
at  stool  for  some  days,  when,  on  the  morning  of  the  22d  of  June,  he  was  seized 
on  a sudden,  at  the  time  he  was  going  to  breakfast,  with  acute  abdominal  pains, 
the  seat  of  which  were  principally  around  the  umbilicus.  At  the  time  he  took 


DISEASES  OF  THE  ABDOMEN. 


299 


an  opiate  mixture.  In  the  course  of  the  day  the  pains  were  a little  mitigated, 
but  during  the  night  they  reappeared  with  renewed  intensity.  We  saw  him 
on  the  next  morning,  when  he  was  in  the  following  state  : countenance  was 
pale  and  expressive  of  the  most  intense  anxiety ; the  eyes  were  dull  and  sunk  ; 
the  pains  of  the  abdomen  were  very  acute,  and  even  intolerable ; pressure  nei- 
ther increased  nor  relieved  them  ; no  stool ; tongue  natural  ; no  vomiting  ; com- 
plete apyrexia  ; two  ounces  of  castor-oil  were  prescribed  ; seven  very  copious 
alvine  evacuations  took  place.  In  the  evening  the  patient  found  himself  con- 
siderably relieved  ; he  slept  well  during  the  night.  On  the  24th  he  again  took 
some  castor-oil.  On  the  25th  he  no  longer  felt  any  pain.  On  the  26th  some 
small  red  conical  pimples  appeared  over  the  abdomen  ; two  days  after  these 
spots  disappeared.  The  patient  went  out  perfectly  well. — In  this  case  the 
abdominal  pains  readily  yielded  the  moment  that  alvine  evacuations  were  ob- 
tained. In  other  instances  we  have  seen  these  pains  much  more  obstinate,  and 
disappear  at  intervals  in  order  to  return  again.  We  saw  them  in  one  case  con- 
tinue for  more  than  a month,  not  constantly  but  so  that  they  returned  by  irre- 
gular succession,  which  gradually  became  more  distant,  less  severe,  and  ulti- 
mately terminated  no  longer  to  reappear.  In  this  case,  moreover,  we  observed 
a phenomenon  which  was  not  observed  in  the  other  patients  ; when  the  pain 
reappeared,  a very  hard  tumour,  seemingly  formed  by  the  intestinal  convolutions 
packed  together,  presented  itself  in  one  point  of  the  abdomen  ; this  tumour  con- 
tinued as  long  as  the  pain  was  felt ; it  disappeared  along  with  it,  and  then  the 
abdomen  again  became  soft  and  free  from  pain  ; there  never  was  the  least  ap- 
pearance of  fever.  At  the  commencement  of  this  disease  leeches  were  repeat- 
edly applied  to  the  abdomen  without  any  benefit.  Castor-oil  was  then  given 
several  times,  which,  every  time  it  was  given,  produced  very  copious  alvine 
evacuations  ; different  preparations  of  opium  were  also  given  several  times. 

There  is  another  species  of  colic  which  presents  symptoms  more  evidently 
inflammatory  than  the  preceding  species,  that  which  is  attributable  to  the  habi- 
tual handling  of  copper.  It  is  frequently  observed  at  the  Charite  in  copper- 
founders,  and  in  other  persons  who  are  employed  in  various  kinds  of  copper 
works.  This  colic  differs  from  lead-colic,  1st,  in  the  less  severity  of  the  pain  ; 
2dly,  in  the  existence  of  purging  ; 3dly,  in  the  greater  frequency  of  an  accom- 
panying fever  ; in  a word,  it  appears  to  be  much  more  than  lead-colic,  the  result 
of  a real  inflammation  of  the  digestive  tube.  However,  in  such  cases,  we  have 
frequently  seen  M.  Lerminier  successfully  employ  those  active  evacuants  which 
form  the  basis  of  lead-colic  ; the  number  of  the  stools,  thus  artificially  produced, 
then  diminished,  and  after  copious  vomiting  and  profuse  alvine  evacuations  had 
been  obtained,  the  health  was  re-established.  Would  it  not  appear  that  the 
good  effects  of  purgatives  in  such  cases  was  owing  to  their  promptly  expelling 
from  the  system  the  coppery  particles  which  occasioned  the  phenomena  ? 

We  shall  cite  here  a single  fact  of  this  kind,  remarkable  for  the  symptoms  of 
dysentery  which  existed. 

Case  9. — Colic  from  copper — Symptoms  of  dysentery — Ordinary  treatment  of  lead-colic — 

Rapid  cure. 

A copper  founder,  about  fifty  years  of  age,  had  been  in  the  habitual  enjoyment 
of  good  health.  When  he  entered  the  Charite,  he  had  been  suffering  for  about 
fifteen  days  with  abdominal  pains,  which  at  intervals  became  so  acute  as  to 
occasion  faintness. 

Since  the  last  eight  days  he  felt  very  painful  tenesmus  ; he  was  tormented 
with  a continual  desire  to  go  to  stool,  and  then,  after  great  straining,  passed 
nothing  but  some  thready  mucus,  frequently  tinged  with  blood.  The  abdominal 
pain  was  not  increased  by  pressure  ; the  tongue  had  a natural  appearance,  the 
countenance  was  pale,  and  the  features  sharpened  ; there  was  but  slight  accele- 
ration of  the  pulse  without  much  heat  of  skin. 


300 


ANDRAL’S  MEDICAL  CLINIC. 


On  the  first  day  M.  Lerminier  ordered  fifteen  leeches  to  be  applied  to  the 
anus.  On  the  next  day  no  improvement  was  observed  ; he  then  resolved  on 
employing  the  treatment  for  lead-colic.  From  the  second  day,  after  copious 
evacuations,  the  abdominal  pains  were  very  much  diminished,  the  tenesmus 
was  gone.  This  treatment  was  continued  ; all  the  symptoms  of  dysentery 
ceased,  and  the  patient  soon  left  the  hospital  in  perfect  health.* 


SECOND  BOOK. 

ON  DISEASES  OF  THE  LIVER,  AND  ITS  APPENDAGES. 

1.  The  liver  is  one  of  the  organs  whose  diseases,  by  reason  of  their  severity 
and  frequency,  have  been  most  studied  ; and  yet  among  the  numerous  alterations, 
of  which  it  may  be  the  seat,  there  are  still  several  whose  nature  is  far  from 
being  well  determined,  and  whose  symptoms  are  very  obscure.  What  is  now 
about  to  be  presented  to  the  reader  is  not  a treatise  on  diseases  of  the  liver,  but 
some  researches  and  observations  on  several  points  of  the  history  of  these  dis- 
eases. Besides  that  a treatise  of  this  kind  does  not  enter  into  the  plan  of  our 
work,  we  think  that  the  time  is  not  yet  come,  when  we  can  publish  with  advan- 
tage a complete  history  of  the  diseases  of  the  liver ; those  who  may  at  a future 
period  engage  in  such  an  undertaking,  will  be  enabled  to  find  some  useful 
materials  in  bur  work,  which  is  the  principal  end  we  have  in  view.  In  our 
first  section  we  shall  speak  of  affections  of  the  parenchymatous  structure  of  the 
liver;  and  in  a second,  of  those  of  the  passages  for  the  excretion  of  bile. 


SECTION  I. 

DISEASES  OP  THE  PARENCHYMA  OP  THE  LIVER. 

CHAPTER  I. 

LESIONS  FOUND  IN  THE  LIVER  AFTER  DEATH. 

2.  Of  the  different  alterations  of  the  liver  some  are  preceded  or  accompanied 
by  a greater  or  less  afflux  of  blood  ; in  others,  on  the  contrary,  there  is  a real  or 
apparent  diminution  in  the  quantity  of  blood  which  the  liver  should  receive  in 
its  normal  state : such  is  the  first  result  to  which  observation  leads.  The 
morbid  states  wherein  increase  afflux  of  blood  may  be  demonstrated  directly  or 
indirectly,  are  increase  in  the  size  of  the  liver,  its  hypertrophy,  its  induration, 
the  formation  of  pus  or  of  other  accidental  products  within  its  parenchyma. 
The  morbid  states  wherein  it  seems  that  a diminution  in  the  afflux  of  blood 

* Even  in  cases  where  the  dysenteric  symptoms  are  not  produced,  as  here,  by  a specific  cause, 
a treatment  different  from  that  which  is.  properly  called  the  antiphlogistic  treatment  may  be 
employed  with  undeniable  benefit.  For  the  last  two  years  we  have  given  to  all  the  patients 
labouring  under  dysentery,  who  were  admitted  into  our  wards  at  the  Pitie,  twenty-four  grains 
of  ipecacuanha.  All,  after  having  vomited  more  or  less  copiously,  have  been  cured  very 
rapidly,  and  from  the  second  or  third  day  at  most  after  the  administration  of  the  ipecacuanha 
the  symptoms  of  dysentery  disappeared.  In  all  the  dysentery  was  rather  slight,  and  was  not 
accompanied  by  any  febrile  disturbance. 


DISEASES  OF  THE  ABDOMEN. 


301 


should  be  admitted,  are  its  loss  of  colour  and  its  atrophy.  We  may  designate, 
if  vve  will,  the  different  morbid  states  of  the  liver  where  there  is  increased 
sanguineous  congestion  by  the  generic  term  hepatitis ; but  it  then  becomes 
necessary  to  understand  the  import  of  this  term,  and  not  to  suppose  that,  once 
adopted,  it  will  account  for  the  changes  of  nutrition,  as  numerous  as  they  are 
varied,  which  the  hepatic  organ  may  present : all  that  it  indicates  is  the  com- 
mon element  which  concurs  in  the  production  of  these  changes,  namely,  san- 
guineous congestion.  But  what  is  the  cause  of  the  numerous  differences  of 
these  changes  ? It  cannot  certainly  be  found  in  the  duration  or  intensity  of  the 
sanguineous  congestion.;  for  whether  it  be  short  or  long-continued,  intense  or 
slight,  we  perceive  every  kind  of  change  of  nutrition  indifferently  produced. 
For  the  development  of  each  of  these  species,  it  is  therefore  necessary  to  admit 
certain  peculiar  elements  whose  nature  escapes  us,  and  whose  existence,  how- 
ever, appears  to  me  as  clearly  demonstrated  as  is  that  of  that  of  the  common 
element  of  sanguineous  congestion.  There  are  cases,  moreover,  where  it  is 
only  by  analogy  and  by  the  generalising  of  particular  facts,  that  this  common 
element  can  be  admitted  ; for  the  symptoms  did  not  discover  it  during  life,  and 
after  death  its  existence  is  asserted  or  supposed  only  by  considering  the  products 
found  in  the  liver,  products  which  we  see  become  developed  in  other  organs 
after  sanguineous  congestions,  whose  existence  is  in  general  very  evident. 
This  is  the  case  with  several  accidental  productions,  as  tubercles  and  cancers. 
It  may  happen  also  that  even  in  eases  where  the  liver  is  found  receiving  less 
nourishment  than  in  its  normal  state,  divested  of  colour  and  atrophied,  this  state 
may  have  been  preceded,  like  the  others,  by  a sanguineous  congestion  or  an 
inflammation.  In  order  to  justify  this  assertion,  I might  find  analogous  cases 
in  other  organs ; and  in  the  liver  itself  I might  show  between  these  different 
cases  an  identity  of  symptoms  and  of  occasional  causes.  Thus,  for  instance, 
of  four  individuals  received  into  the  Charite,  in  whom  the  origin  of  the  affec- 
tion of  the  liver  seemed  to  have  been  external  violence,  and  in  whom  also  there 
had  been  at  the  onset  of  the  disease  pain  in  the  hepatic  region,  the  first  pre- 
sented a deep  abscess  in  the  parenchyma  of  the  liver  ; the  second  hydatids  ; the 
third  cancerous  masses  .;  the  fourth  diminution  in  the  size  of  the  organ.  These 
facts  are  too  important  to  be  lost  sight  of.  In  admitting  also  as  a consequence 
of  a certain  number  of  facts  that  atrophy  of  the  liver  may  result  from  a primary 
inflammation  of  this  organ,  it  does  not  by  any  means  follow  that  such  must  be 
always  the  case. 

Besides  simple  atrophy,  and  its  loss  of  colour,  there  are  probably  other  patho- 
logical states  of  this  organ,  the  cause  of  which  might  also  be  fairly  referred  to  a 
diminution  and  real  retrogradation  of  the  act  of  nutrition.  What,  for  instance, 
is  the  fatty  degeneration  of  the  liver?  If,  in  order  to  solve  this  question,  we 
observe  in  what  cases  different  fatty  substances  come  to  be  developed  acci- 
dentally in  the  system,  we  shall  see  that  it  is  very  frequently  around  or  in  the 
site  of  certain  organs  which  are  become  atrophied;  we  shall  find,  moreover, 
that  that  which  exists  morbidly  in  man  is  a law  of  the  physiological  state  in 
the  animal  kingdom  ; and  that,  for  instance,  in  beings  whose  brain  is  but  little 
developed  (as  in  fishes,  etc.),  the  place  which  the  encephalic  mass  does  not 
occupy  is  occupied  by  an  accumulation  of  fatty  substances.  Is  it  not  also  in 
the  place  of  the  atrophied  molecules  of  the  liver  that  the  fat  is  deposited.  What 
again  is  the  formation  of  the  serous  cysts  in  the  substance  of  the  liver?  With 
respect  to  this  point  see  what  takes  place  in  other  organs.  Should  they  be 
arrested  in  their  development,  serous  pouclres  are  found  in  them,  so  that  it  is 
possible  that  several  of  these  cysts  of  the  liver,  considered  as  the  result  of  its 
inflammatory  state,  attest  probably  the  existence  of  an  entirely  opposite  state 
of  diminished  nutrition.  What  is,  in  fine,  the  cause  of  those  vesicular  worms 
so  frequently  found  in  the  liver  ? Would  it  be  absurd  to  seek  it  in  an  atrophied 
26 


302 


ANDRAL’S  MEDICAL  CLINIC. 


state  of  the  parenchyma  of  the  liver?  We  might' say  that  nature,  no  longer 
able  to  nourish  this  organ,  was  now  confined  to  an  inferior  process  of  organisa- 
tion, and  instead  of  producing  the  molecules  of  an  organ  of  a mammiferous 
animal,  she  developed  a hydatid.  I give  those  different  ideas  merely  as  con- 
jectures more  or  less  probable,  but  which  seem  to  me  unworthy  neither  of 
examination  nor  discussion ; they  prove  at  least  that  there  are  still  researches 
to  be  made. 

3.  The  first  study  to  be  undertaken  in  order  to  arrive  at  any  exact  knowledge 
regarding  the  nature  of  the  diseases  of  the  liver,  is  to  endeavour  clearly  to  under- 
stand their  anatomical  characters.  To  arrive  at  this,  the  best  method  in  my 
opinion  is  to  commence  at  the  consideration  of  the  healthy  state  of  the  liver, 
clearly  to  determine  this,  and  then  to  endeavour  to  ascertain  the  share  which  the 
different  anatomical  elements  of  the  liver  may  have  in  the  formation  of  its  dif- 
ferent changes  of  texture.  This  is  undoubtedly  the  only  road  which  can  lead  to 
any  useful  results.  But  is  it  practicable  in  the  present  state  of  science  ? We 
shall  be  able  to  judge  of  that  by  the  detail  of  the  researches  in  which  I have 
been  engaged  on  this  head  : in  trying  to  enter  on  a route  almost  novel,  I could 
not  be  expected  to  make  much  way,  but  I am  obliged  to  take  particular  care  not 
to  stray  from  the  path. 

4.  Two  substances  exist  naturally  in  the  liver:  they  are  so  arranged  as  to 
represent  tolerably  well  the  form  of  a sponge.  One  of  these  substances,  of  a 
more  or  less  marked  white  colour,  according  to  the  case,  represents  the  solid 
part  of  the  sponge  ; it  only  contains  some  large  vessels  which  traverse  it  with- 
out ramifying  through  it ; consequently  it  contains  but  very  little  blood.  In  its 
areolae  the  other  substance  is  as  it  were  deposited,  which  is  red,  extremely  vas- 
cular, of  a cavernous  appearance,  and  appearing  very  susceptible,  like  all  erectile 
tissues,  of  increasing  and  diminishing  in  size. 

In  what  I consider  the  normal  state  of  the  liver,  these  two  substances  are 
distinct  to  the  observer  only  when  disease  has  rendered  them  more  prominent. 
If  in  this  presumed  normal  stale  we  examine  a slice  of  the  tissue  of  the  liver, 
we  find  it  to  consist  of  an  intensely  red  substance,  separated  into  several  com- 
partments by  white  lines  of  a slight  tinge  of  rose  colour,  which  interlace  in 
different  directions,  and  form  as  it  were  circumvolutions.  Does  the  liver  con- 
tain a great  quantity  of  blood  ? The  white  substance  becomes  coloured,  and  the 
organ  acquires  a uniform  red  tint ; this  exists  normally  in  the  foetus,  and  acci- 
dentally in  the  adult,  under  several  circumstances  which  shall  be  noticed  presently. 
On  the  contrary,  should  the  liver  contain  less  blood  than  is  compatible  with  its 
physiological  state,  the  white  substance  becomes  at  first  very  apparent,  then  in 
a still  more  advanced  degree  of  this  species  of  local  anemia,  the  red  substance 
itself  becomes  devoid  of  colour,  and  the  liver  presents  a whitish  tint,  in  which 
an  attentive  examination  still  discovers  the  two  substances.  These  different 
shades  of  appearance  in  the  liver  depends  solely  on  the  proportions  of  blood 
which  it  contains,  and  such  must  be  taken  into  account.  But  further,  different 
changes  may  attack  the  two  substances  which  1 have  just  described  separately  or 
simultaneously,  whence  there  will  be  occasioned  in  the  liver  different  appear- 
ances which  constitute  so  many  morbid  states.  Let  us  study  first  the  separate 
alterations  of  each  of  these  substances. 

A rather  common  alteration  of  the  white  substance  is  its  hypertrophy.  In 
the  first  stage  this  is  marked  by  lines  and  circumvolutions,  which  remain  very 
apparent,  even  in  the  case  where  the  liver  is  most  gorged  with  blood.  In  the 
second  stage  these  lines  are  seen  to  become  changed  into  patches  more  or  less 
extensive  ; the  white  substance  being  thus  hypertrophied  becomes  hardened, 
and  may  acquire  the  fibrous  appearance.  This  hypertrophied  substance  modi- 
fied in  its  form,  in  its  consistence,  and  in  its  colour,  might  be  readily  taken  for 
a newly  formed  tissue,  did  we  not  follow  gradually  its  different  stages.  An  error 
of  this  kind  has  in  my  opinion  been  committed  by  Laennec.  The  lesion  of  the 


DISEASES  OF  THE  ABDOMEN". 


303 


liver  which  he  called  cirrhosis,  and  which  he  considered  as  an  accidental  tissue, 
seems  to  me  solely  the  resultj  of  a certain  degree  of  hypertrophy  of  the  white 
substance.  This  cirrhosis  carefully  examined  in  its  different  phases  of  develop- 
ment, seems  to  me  to  be  no  more  an  accidental  tissue  than  the  pulmonary  gra- 
nulations are,  which  I have  elsewhere  proved  to  be  nothing  else  than  partial 
inflammations  of  the  lung. 

I have  already  said  that  the  red  substance  might  be  differently  coloured  and 
tumefied  according  to  the  variable  quantities  of  blood  which  it  contained.  It 
may  also  undergo  real  hypertrophy,  the  result  of  which  will  be,  according  to 
the  case,  the  granulated  or  lobulated  appearance  of  the  liver.  At  other  times 
this  same  red  substance  undergoes  an  entire  loss  of  colour,  or  else  it  becomes 
really  atrophied  ; and  in  this  case  there  is  a diminution  in  the  size  of  the  liver. 
Finally,  it  is  in  the  interior  of  this  red  substance  that  the  different  morbid  secre- 
tions so  often  seated  in  the  liver  appear  to  take  place. 

5.  The  changes  of  these  two  substances  separate,  or  combined  in  different 
ways,  produce  the  several  morbid  states  of  the  hepatic  parenchyma.  These 
morbid  states  are  principally  : 1st,  different  degrees  of  sanguineous  congestions, 
active  or  passive,  vital  or  mechanical  ; 2d,  alterations  of  nutrition  ; 3d,  alter- 
ations of  secretion. 

6.  Sanguineous  congestions  of  the  liver  are  similar  to  those  which  may  take 
place  in  any  parenchymatous  tissue,  in  the  brain  or  lung  for  example.  Some- 
times the  cause  which  produces  them  is  purely  mechanical ; an  obstacle,  for 
instance,  to  the  free  passage  of  the  blood  through  the  right  cavities  of  the  heart, 
whence  arises  a reflux  and  accumulation  of  this  liquid  in  the  hepatic  vessels. 
Sometimes  this  cause  is  not  mechanical ; but  it  does  not  yet  consist  in  an  excess  of 
vitality,  in  what  is  called  the  inflammatory  stimulus.  Such  are  the  congestions 
existing  in  the  liver  in  scorbutic  individuals.  I know  not  whether  such  conges- 
tions may  be  called  passive  in  the  sense  ordinarily  attached  to  this  term.  But 
what  appears  to  me  very  evident  is,  that  nothing  less  resembles  an  inflammatory 
process  than  those  sanguineous  congestions  which  take  place  simultaneously  in 
several  organs  in  scorbutic  persons.  Every  time  I had  an  opportunity  of  open- 
ing the  bodies  of  those  patients,  I found  the  liver  very  much  gorged  with  blood  ; 
this  liquid  oozed  from  every  part  of  it,  and  the  tissue  of  the  organ  then  present- 
ed a uniform  red  tint;  a similar  engorgement  was  detected  in  the  spleen.  In 
other  cases  the  blood  accumulates  in  an  extraordinary  manner  in  the  liver,  under 
the  influence  of  an  inflammatory  stimulus.  This  active  congestion  may  con- 
tinue for  a longer  or  shorter  time,  without  any  other  alteration  supervening, 
except  in  most  cases  a modification  in  the  secretion  of  bile.  If  we  would  keep 
to  mere  observation,  certainly  such  a state  cannot  be  distinguished  from  what  is 
called  inflammation,  nothing  else  is  found  in  any  of  the  other  organs  to 
prove  their  inflammation,  before  there  is  alteration  in  their  texture  ; in  all,  as 
in  the  liver,  this  congestion,  whatever  be  its  degree  or  duration,  is  accompanied 
by  an  increase  in  the  size  of  the  tissue  which  is  its  seat,  and  most  frequently 
by  an  increase  in  its  normal  secretion.  In  the  liver,  as  every  where  else,  this 
congestion  may  remain  the  only  modification  which  the  organ  has  undergone, 
and  which  returns  immediately  to  its  normal  state  the  moment  it  ceases.  But 
at  other  times  it  is  the  origin  and  commencement  of  a great  number  of  changes 
which  become  developed  in  the  organ  wherein  it  is  seated  ; and  it  must  be  con- 
sidered as  one  of  the  elements  of  their  formation. 

Sanguineous  congestions  of  the  liver,  whatever  be  their  cause,  may  be  either 
general  or  partial.  In  the  first  case,  whatever  be  their  degree,  the  size  of  the 
organ  is  increased  ; it  is  observed  to  pass  more  or  less  beyond  the  cartilages  of 
the  ribs,  or  to  press  the  diaphragm  upwards.  Such  an  increase  in  size  takes 
place  sometimes  with  great  rapidity,  and  disappears  in  the  same  way ; this 
principally  happens  in  those  cases  of  hepatic  congestions  which  accompany 


304 


ANDRAL’S  MEDICAL  CLINIC. 


diseases  of  the  heart ; often  then,  after  bloodletting  has  been  employed,  and  the 
circulation  becomes  less  disturbed,  the  liver  ceases  somewhat  abruptly  to  be  any 
longer  felt ; it  ascends  behind  the  ribs,  and  redescends  again,  if  the  disease  of 
the  heart  becomes  exasperated.  But  from  the  sole  circumstance  that  there  is  an 
habitual  stagnation  of  blood  in  the  liver  greater  than  usual,  there  is  a disposition 
to  irritation  of  this  organ,  and,  after  a certain  time,  to  the  merely  mechanical 
congestion  of  the  liver  there  may  be  added  a real  active  vital  congestion  ; this 
latter  state  may  continue  alone,  or  be  followed  by  different  disturbances  of 
nutrition.  Thence  the  great  frequency  of  consecutive  diseases  of  the  liver  in 
persons  labouring  under  organic  affections  of  the  heart. 

In  some  cases  the  sanguineous  congestion  of  the  liver  is  but  partial ; red  spots 
are  found  scattered  over  its  surface  or  through  its  interior,  from  which  a con- 
siderable quantity  of  blood  flows  on  making  an  incision.  Such  partial  conges- 
tions are  seldom  the  result  of  a mere  mechanical  cause;  for  it  is  not  easily  seen 
why  this  latter  should  cause  its  action  to  be  felt  on  one  particular  part  of  the 
liver  rather  than  on  another. 

It  is  evident  that  in  these  different  degrees  of  congestion  the  red  substance  of 
the  liver  performs  the  principal  part. 

These  congestions,  without  any  other  alteration  of  texture,  constitute  a cer- 
tain number  of  diseases  of  the  liver,  indicated  during  life  by  different  symptoms 
which  vary  according  to  the  intensity  of  the  congestion,  its  extent,  the  rapidity 
with  which  it  has  taken  place,  and  the  cause  which  has  given  rise  to  it. 

Not  only  under  the  influence  of  the  conditions  just  enumerated  may  the  ves- 
sels of  the  liver  receive  a greater  quantity  of  blood  than  is  allotted  to  them  in 
their  normal  state,  but  moreover,  whether  there  may  have  been  previous  con- 
gestion or  not,  they  may  become  ruptured,  and  so  give  rise  to  hemorrhage  more 
or  less  profuse,  an  effusion  of  blood  into  the  parenchyma  of  the  liver,  a sort  of 
hepatic  apoplexy.  The  most  remarkable  case  of  this  kind  which  I have  seen 
is  the  following  : 

M.  S.  enjoyed  tolerably  good  health,  and  had  never  presented  any  particular 
symptom  indicating  the  existence  of  disease  of  the  liver,  when  one  morning  on 
awaking  he  felt  rather  ill,  and  complained  of  some  pains  in  the  abdomen  : he 
expressed  a wish  to  remain  in  bed,  and  he  was  left  alone  in  his  bed-chamber. 
In  a few  hours  after,  some  one  went  into  his  room,  and  he  was  found  dead.  I 
opened  his  body  in  the  presence  of  some  other  physicians.  The  organs  of  the 
cranium  and  thorax,  in  which  one  might  expect  to  find  the  cause  of  his  sudden 
death,  presented  no  change  whatever.  The  peritoneum  was  found  to  be  filled 
with  a great  quantity  of  black  blood  partly  coagulated  ; several  clots  were  accu- 
mulated principally  between  the  diaphragm  and  the  convex  surface  of  the  liver. 
Towards  the  centre  of  the  right  lobe,  and  on  the  convex  surface,  we  discovered 
an  opening  large  enough  to  admit  the  extremity  of  the  little  finger.  This  open- 
ing was  the  orifice  of  a cavity  in  the  parenchyma  of  the  liver,  large  enough  to 
contain  an  egg,  and  filled  with  blood.  A large  vessel,  which  had  been  torn, 
opened  on  a point  of  this  cavity  : a stylet  having  been  introduced,  penetrated 
into  the  trunk  of  the  vena  portae,  of  which  this  vessel  was  one  of  the  principal 
divisions.  The  cause  of  death  and  the  source  of  the  hemorrhage  were  now 
manifest.  The  parenchyma  of  the  liver  had  retained  its  healthy  state  around 
the  accidental  cavity  which  contained  the  blood. 

Dr.  Honore  lately  presented  to  the  Academy  a liver  in  which  were  several 
cavities  containing  pure  blood.  In  this  case  we  are  not  certain  whether  this 
blood  was  supplied  by  torn  vessels,  or  whether  it  was  the  product  of  mere  ex- 
halation. In  his  excellent  Essay  on  Abscess  of  the  Liver,  M.  Louis  has  cited 
the  case  of  an  individual  in  whose  liver  there  was  found  a cavity  as  large  as  a 
nut,  containing  a fibrinous  coagulum  of  black  blood  arranged  in  concentric  layers. 
No  laceration  was  discovered  in  any  of  the  bloodvessels. 


DISEASES  OF  THE  ABDOMEN. 


305 


7.  The  liver  may,  as  we  have  already  stated,  undergo  considerable  changes 
in  its  nutrition,  consecutively  on  a sanguineous  congestion  variable  in  intensity 
and  duration.  Among  these  changes,  for  instance,  we  must  place  its  general 
or  partial  hypertrophy.  The  increase  of  size,  which  may  also  be  general  or 
partial,  which  it  then  undergoes,  is  no  longer  merely  the  result  of  a mere  accu- 
mulation of  blood  in  its  tissue,  but  rather  of  an  increase  in  the  size  or  in  the 
number  of  the  molecules  of  the  latter;  in  other  words,  under  a given  volume  it 
contains  more  solid  parts,  or  has  greater  density.  If  this  hypertrophy  of  the 
liver  be  general,  there  is  an  increase  of  size  in  the  entire  organ ; sometimes, 
however,  this  size  is  not  increased,  but  the  tissue  is  denser  and  harder,  and 
there  is  more  difficulty  in  dividing  it  with  the  scalpel.  Thus  in  many  cases  of 
hypertrophy  of  the  osseous  system,  the  latter  has  not  increased  in  size,  but  has 
only  acquired  greater  specific  gravity. 

It  may  happen  that  hypertrophy  of  the  liver  exists  only  in  one  of  its  sub- 
stances, the  other  retaining  its  normal  state,  or  undergoing  at  the  same  time  a 
real  atrophy.  If  the  latter  occurrence  takes  place,  there  may  result  a diminu- 
tion in  the  general  size  of  the  liver,  though  one  of  its  anatomical  elements  may 
have  a greater  volume  than  usual.  This  is  what  occurs,  for  instance,  in  seve- 
ral cases  of  cirrhosis , which  we  have  seen  to  be  nothing  else  than  hypertrophy 
of  the  white  substance.  At  the  same  time  that  the  nutrition  of  the  latter  has 
attained  unusual  activity,  the  red  substance  has  undergone  a sort  of  shrinking, 
and  consecutively  to  its  atrophy  the  size  of  the  liver  has  diminished.  The 
difficulty  with  which  injections  are  made  to  pass  into  the  substance  of  the  liver 
in  such  cases,  the  ascites  which  almost  uniformly  follows  this  atrophy  of  the 
red  substance,  whence  arises  a sort  of  ratatine  appearance  of  the  liver,  seem 
to  prove  that  there  then  takes  place  obliteration  of  a great  number  of  the  small 
vessels  which  constitute  this  red  substance.  Oftentimes  also  unequal  hyper- 
trophy of  some  granulations,  whether  isolated  and  thinly  scattered,  or  numerous 
and  clustered  together,  coincides  with  perceptible  diminution  in  the  size  of  the 
liver,  which  depends  on  atrophy  of  other  portions  of  the  red  substance,  or  of 
the  white  substance. 

Hypertrophy  of  the  liver,  whether  partial  or  general,  is  most  frequently  ac- 
companied by  an  increase  of  its  consistence.  It  may  exist  with  different  shades 
of  colour,  the  principal  of  which  are  the  red,  yellow,  greenish,  brown,  grey,  or 
even  white  tint.  Several  of  these  tints  are  often  blended  together,  from  which 
results  the  most  varied  appearances  of  the  liver,  which  I shall  endeavour  to 
point  out  in  the  particular  cases. 

There  are  instances  where  the  liver,  with  respect  to  its  form,  size,  colour, 
and  the  proportion  of  its  substances,  appears  to  be  in  its  natural  state  ; but  its 
consistence  is  very  much  diminished  ; its  tissue  is  extremely  friable  ; it  crumbles 
and  is  reduced  to  a pulp  under  the  pressure  of  the  finger  ; it  sometimes  pos- 
sesses not  more  consistence  than  the  substance  resembling  wine  lees,  which 
fills  the  areolae  of  the  spleen.  No  doubt  the  analogy  with  that  which  takes 
place  in  other  organs,  and  still  more  the  cases  wherein  this  softening  of  the 
liver  has  been  observed  to  coincide  with  all  the  symptoms  of  hepatitis,  should 
incline  us  to  admit  that  this  softening  is  the  result  of  an  inflammatory  process. 
However,  convinced  as  I am  that  a great  number  of  softenings  succeed  inflam- 
mation, I feel  some  hesitation  in  admitting  that  this  is  the  case  for  all  ; I have 
not  sufficient  proofs  to  enable  me  to  come  to  a final  decision  on  this  point.  I 
ask  every  fair  reasoning  man,  has  he  not  met  cases  wherein  a softening  exist- 
ing in  the  brain,  stomach,  liver,  &c.,  he  has  still  been  unable  to  say  that  any 
species,  of  sanguineous  congestion,  any  process  of  irritation  whatever,  has  pre- 
ceded or  accompanied  the  softening  of  which  these  organs  were  the  seat  ? In 
these  difficult  cases  let  us  learn  to  doubt  and  to  wait. 

Persons  have  frequently  spoken  of  an  increase  in  the  size  of  the  lobulus  Spi- 
26* 


306 


ANDRAL’S  MEDICAL  CLINIC. 


gelii.  an  increase  so  considerable  that  this  lobe  formed  a tumour  sensible  to  the 
touch.  Among  the  numerous  patients  examined  at  the  Charite  and  elsewhere 
during  their  life  or  after  death,  none  presented  this  kind  of  alteration  of  the 
liver,  which,  according  to  several  physicians,  should  be  very  common  ; never 
during  life  have  we  been  able  to  feel  the  lobulus  Spigelii  through  the  abdominal 
parietes,  and  never,  after  death,  have  we  ascertained  its  hypertrophy  indepen- 
dent of  that  of  the  rest  of  the  liver.  We  must  then  consider  those  tumours 
formed  by  the  lobulus  Spigelii,  an  occurrence  as  uncommon  as  a tumour  would 
be,  formed  either  by  an  aneurism  of  the  cceliac  trunk,  or  by  a disease  of  the 
pancreas.* 

With  respect  to  the  two  principal  lobes  of  the  liver,  they  are  often  found 
hypertrophied  or  atrophied  separately  one  from  the  other.  The  right  lobe,  for 
instance,  may  be  much  larger  than  ordinary,  and  the  left  lobe  consist  merely  of 
a very  slight  appendix.  At  other  times  the  right  lobe  is,  on  the  contrary,  dimin- 
ished in  size ; it  occupies  but  a small  portion  of  its  usual  place,  whilst  the  left 
lobe  having  become  hypertrophied,  extends  much  more  than  usual  into  the  left 
hypochondrium,  and  may  even  be  the  cause  of  a dull  sound  on  the  inferior  left 
side  of  the  thorax.  In  this  case  the  liver  of  the  adult  resembles  that  of  the 
foetus,  in  which  the  left  lobe  has  greatly  the  advantage  over  the  right  in  respect 
to  size. 

8.  The  last  order  of  changes  of  the  liver  consists  in  the  morbid  secretions 
which  may  take  place  into  its  parenchyma.  Thus,  pus  may  infiltrate  it,  or  an 
abscess  may  be  formed  in  it. 

Four  leading  circumstances  may  be  noticed  in  which  the  liver  becomes  the 
seat  of  abscess.  These  abscesses  are  formed;  1st,  after  external  violence, 
which  acts  directly  on  the  liver  ; 2dly,  after  traumatic  lesions  of  the  brain ; 
3dly,  spontaneously  as  a termination  of  acute  or  chronic  hepatitis  : this  case  is 
more  uncommon  than  the  two  preceding.  4thly,  Finally,  there  are  circum- 
stances where  the  pus  found  in  the  liver  does  not  appear  to  be  accumulated  in 
consequence  of  an  hepatitis  ; having  been  formed  elsewhere,  and  carried  into  the 
torrent  of  the  circulation,  one  might  say  that  it  has  been  merely  separated  from 
the  blood  in  the  interior  of  the  liver.  In  such  cases  no  symptom  of  hepatitis 
has  existed  during  life : neither  is  any  trace  of  inflammation,  or  of  any  morbid 
process  whatsoever  found  after  death  around  the  purulent  collection  ; very  fre- 
quently also  similar  abscesses  are  found  at  the  same  time  in  other  parts,  in  the 
lung,  spleen,  brain,  and  in  the  subcutaneous  and  intermuscular  cellular  tissue ; 
and  in  none  of  these  parts  has  the  formation  of  pus  been  preceded  by  signs  of 
inflammation,  and  lastly,  this  species  of  abscess  is  produced  chiefly  in  given  con- 
ditions of  the  system,  namely,  after  capital  operations,  or  puerperal  metro-peri- 
tonitis, or  when  a profuse  suppuration,  which  had  been  kept  up  for  a longtime, 
has  been  suddenly  arrested.  We  shall  cite  at  another  time  facts  relative  to 
these  different  species  of  abscess ; suppuration  of  the  liver  is,  moreover,  a very 
uncommon  affection. 

Instead  of  pus,  the  tissue  of  the  liver  may  secrete  different  substances,  some- 
times yellow  and  friable,  sometimes  more  or  less  resembling  jelly  or  glue. 
These  different  substances,  which,  in  consequence  of  differences  oftentimes  of 
trifling  importance  in  their  physical  qualities,  have  been  called  by  different 
names,  either  tubercles,  or  encephaloid  substance,  or  steatoma,  etc.,  agree  in  the 
common  and  important  character  of  being  secreted  within  the  substance  of  the 
parenchyma  of  the  liver,  and  after  sanguineous  congestion  more  or  less  evident, 
just  as  pus  may  be  secreted  there.  They  are  even  formed  more  frequently  than 
the  latter.  Sometimes  the  tissue  of  the  liver  is  still  apparent  where  these  secretions 

* In  a case  of  cancerous  affection  of  the  pancreas  already  alluded  to,  there  was  no  appreciable 
tumour  during  life  through  the  abdominal  parietes. 


DISEASES  OF  THE  ABDOMEN. 


307 


exists  ; it  is  infiltrated  with  them,  and  at  the  same  time  more  or  less  injected. 
Sometimes  in  order  to  find  the  tissue  of  the  liver,  it  is  necessary  to  have 
recourse  to  careful  dissection  or  to  maceration,  and  then  we  see  shreds  of  it 
in  the  midst  of  foreign  matter,  in  the  same  manner  as  in  a phlegmon  we 
find  shreds  of  the  cellular  tissue  and  of  muscle  in  the  midst  of  pus.  The  tissue 
of  the  liver  is  then  not  merely  compressed,  it  appears  to  be  actually  atrophied 
and  absorbed ; dissection  has  also  convinced  me  of  an  important  fact,  namely, 
that  the  numerous  vessels  oftentimes  seen  to  ramify  in  the  midst  of  white  en- 
cephaloid  masses,  do  not  in  many  cases  belong  to  them  ; that  they  merely  tra- 
verse them,  and  that  they  are  merely  a remnant  of  the  tissue  of  the  liver  to 
which  they  belong.  At  a later  period  these  vessels  may  burst,  and  the  result 
will  be  hemorrhages  more  or  less  profuse. 

Thus  in  more  than  one  case  the  organization  of  a great  number  of  accidental 
productions  belongs  less  to  the  latter  than  to  the  tissues  within  which  they  are 
developed.. 


CHAPTER  II. 

SYMPTOMS  OF  DISEASES  OF  THE  LIVER. 

9.  These  are  few  in  number,  often  too  obscure,  or  too  slightly  marked,  to 
enable  one  always  to  state  positively  the  existence  of  an  affection  of  the  liver. 
Under  other  circumstances  this  is  not  doubtful,  but  it  is  very  difficult,  or  even 
impossible  to  determine  its  nature ; for  on  the  one  hand  similar  symptoms  are 
often  produced  by  several  affections  of  the  liver,  which  present  the  greatest  dif- 
ferences with  respect  to  their  anatomical  characters  ; and  on  the  other  hand,  it 
cannot  be  said  that  in  any  of  these  affections  any  one  invariable  symptom  is  found. 
Jaundice,  for  instance,  may  be  absent  or  present  in  all  the  diseases  of  the  liver; 
there  is  but  one  case  in  which  it  is  never  wanting,  that  is,  when  the  ductus 
choledochus  is  obliterated.  The  object  of  the  present  chapter  shall  be  to  pre- 
sent certain  data  furnished  by  observation,  which  assist,  1st,  in  detecting  the 
existence  of  a disease  of  the  liver  ; 2dly,  in  determining  its  nature. 

10.  The  symptoms  which  manifest  themselves  in  diseases  of  the  liver  are 
either  local  or  general ; there  are  many  cases  where  the  latter  are  much  more 
marked  than  the  former.  We  shall  speak  of  both  in  their  respective  order. 


e 

ARTICLE  I. 

i 

LOCAL  SYMPTOMS  OF  DISEASES  OF  THE  LIVER. 

11.  Among  the  local  symptoms  we  first  find  pain  ; this  is  as  variable  in  its 
intensity  as  in  its  seat ; in  some  patients  it  is  wandering,  changeable,  and  like 
in  this  respect  to  a rheumatic  pain ; it  may  exist  over  a considerable  extent  of 
surface  ; thus  in  some  individuals  all  the  lower  part  of  the  chest  on  the  right 
side,  and  the  hypochondrium  of  the  same  side,  are  the  seat  of  a painful  sensa- 
tion. At  other  times  it  exists  only  in  some  circumscribed  points  ; thus  it  is  ob- 
served, 1st,  towards  the  epigastric  region ; 2d,  along  the  cartilaginous  edges  of 
the  false  ribs  of  the  right  side ; 3d,  in  a more  or  less  limited  point  of  the  right 
hypochondrium  ; 4th,  towards  the  lower  and  lateral  part  of  the  thorax  on  the 
right  side,  and  sometimes  over  a very  circumscribed  extent,  as,  for  instance, 


30S 


ANDRAL’S  MEDICAL  CLINIC. 


over  the  space  occupied  by  the  last  false  rib  of  the  right  side ; 5th,  posteriorly 
on  this  same  side  near  the  vertebral  column,  and  if  the  pain  is  then  felt  a little 
high  up,  it  may  be  readily  confounded  with  the  dorsal  pains  of  phthisical  pa- 
tients ; 6th,  in  the  left  hypochondrium,  in  the  place  ordinarily  occupied  either 
by  the  great  cul-de-sac  of  the  stomach  or  by  the  spleen;  7th,  in  different  points  of 
the  abdomen,  such  as  the  umbilicus,  the  flanks,  &c.,  if  they  are  occupied  by  the 
liver  now  increased  in  size.  There  are  other  pains  which  are  felt  not  only  in 
parts  occupied  by  the  liver,  but  also  in  parts  more  or  less  remote  ; they  are 
purely  sympathetic,  and  are  the  result  of  mere  nervous  irritation.  Thus  we 
have  for  a long  time  noticed,  without  being  able  to  account  for  it,  the  fixed  pain 
in  the  right  shoulder,  which  accompanies  certain  affections  of  the  liver;  this 
pain  we  have  found  to  exist  less  frequently  than  has  been  said ; however,  in 
more  than  one  case  we  have  found  it  to  exist  in  a very  marked  manner.  These 
sympathetic  pains  may  again  be  seated  in  other  parts.  We  shall  always  hold 
in  recollection  the  case  of  a patient  whose  liver  was  found  to  contain  an  immense 
number  of  what  are  called  cancerous  masses.  He  had  never  complained  of 
any  pain  in  the  region  of  the  liver ; but  the  two  sides  of  the  chest  became  from 
time  to  time  the  seat  of  a very  painful  sensation,  which  soon  extended  to  the 
arms,  and  as  far  as  the  hand ; the  hand  was  also  the  seat  of  a very  troublesome 
sense  of  formication,  sometimes  very  acute,  lancinating  pains,  passing  like  flashes 
of  fire,  off  one  or  other  of  the  arms.  We  found  nothing  after  death  which 
could  explain  these  symptoms.  We  have  seen  other  patients  who  complained 
only  of  pain  in  the  head  ; this  pain  may  even  be  sufficiently  intense  and  con- 
stant to  engage  exclusively  the  attention  of  the  patient,  the  affection  of  whose 
liver  was  not  indicated  to  him  by  any  local  affection.  Again : a very  extraor- 
dinary phenomenon  which  some  individuals  present  who  are  affected  with  liver 
disease,  is  an  intense  and  very  troublesome  itching  of  the  skin  : this  symp- 
tom principally  exists  when  there  is  jaundice ; but  it  may  also  exist  where  the 
skin  has  retained  its  natural  colour. 

The  pains  felt  in  the  region  of  the  liver,  or  in  the  place  which  it  occupies, 
from  disease,  may  be  continued  or  intermittent.  In  both  cases  they  are  some- 
times very  severe,  and  are  felt  spontaneously  without  being  increased  by  pressure; 
at  other  times  pressure  increases  them  ; at  other  times  again  it  is  only  when 
pressure  is  employed  that  any  pain  is  felt.  There  are  some  persons  who  suffer 
only  when  they  walk,  when  they  are  in  a vehicle,  or  when  they  ascend  or  de- 
scend along  an  inclined  plane,  or  when  they  lie  on  either  side. 

A fixed  pain  in  the  region  of  the  liver  is  often  the  first  symptom  which  ex- 
cites suspicion  that  this  organ  is  diseased.  Some  persons  have  felt  for  a great 
number  of  years  no  other  symptom  with  respect  to  the  liver,  except  a more  or 
less  acute  pain  which  returns  at  intervals  ; their  complexion  was  at  most  a little 
yellow  ; in  other  respects  the  region  of  the  liver  was  soft,  digestion  generally 
good,  and  the  function  of  nutrition  went  on  rather  satisfactorily  ; but  a period 
comes  when  the  old  pain  becomes  more  acute  at  intervals  ; and  when  it  is  thus 
awakened  with  unusual  severity,  fevers  sets  in,  traces  of  jaundice  often  mani- 
fest themselves  ; at  a later  period  these  intermittent  symptoms  become  con- 
tinued, and  the  existence  of  a severe  disease  of  the  liver  is  no  longer  doubtful. 
We  have  already  spoken  of  those  cases  wherein  the  pain  forms  so  predominant 
a symptom,  as  to  form  a separate  disease  under  the  name  of  hepatic  colic.  In 
other  individuals  the  pain  does  not  supervene  till  a long  time  after  other  local  or 
general  symptoms  have  already  announced  the  existence  of  an  affection  of  the 
liver.  Oftentimes  again  this  affection  runs  through  all  its  stages,  and  carries 
the  patient  to  the  grave,  without  any  pain  having  ever  been  felt  in  the  hepatic 
region. 

Several  parts  situate  in  the  vicinity  of  the  liver  may  be  the  seat  of  different 
pains  which  have  been  often  confounded  with  pains  of  the  liver  ; and  it  must  be 


DISEASES  OF  THE  ABDOMEN. 


309 


acknowledged  that  it  is  often  difficult  to  avoid  such  a mistake.  Those  parts,  the 
pains  of  which  simulate  those  of  the  liver,  may  be  situated  either  in  the  thorax, 
or  in  the  abdomen.  In  the  thorax  we  find  certain  inflammations  of  the  pleura, 
and  particularly  of  the  diaphragmatic  pleura,  which  indicate  their  existence  by 
a pain  seated  entirely  in  the  inferior  part  of  the  right  side  of  the  thorax,  along 
the  cartilaginous  edges  of  the  ribs,  and  as  far  as  the  right  hypochondrium. 
One  may  then  feel  disposed  the  more  readily  to  believe  in  the  existence  of  hepa- 
titis, because  jaundice  is  observed  to  supervene,  which  is  probably  the  result  of 
a sympathetic  irritation,  communicated  from  the  diaphragmatic  pleura  to  the 
convex  surface  of  the  liver.  We  certainly  have  in  such  cases  found  an  inflam- 
mation in  the  pleura,  and  no  appreciable  alteration  in  the  organ  which  secretes 
the  bile. 

In  the  abdomen  a partial  peritonitis  occurring  in  the  vicinity  of  the  liver,  an 
acute  or  chronic  inflammation  of  the  pylorus,  or  of  the  commencement  of  the 
duodenum,  a nephritis  even,  or  tumours  developed  between  the  liver  and  kidney, 
or  beneath  the  gastro-hepatic  epiploon,  may  give  rise  to  pain  which  it  would 
often  be  difficult  to  distinguish  from  pain  seated  in  the  liver. 

From  the  existence  of  pain,  its  seat,  nature,  severity,  and  the  time  of  its  ap- 
pearance, can  we  discover  on  what  species  of  affection  of  the  liver  it  depends  ? 
This  has  been  several  times  attempted,  but  in  most  cases  the  rules  laid  down 
on  this  point  may  be  overturned  by  exceptions  almost  as  numerous.  Thus  it 
has  been  said  that  what  are  called  cancerous  affections  of  the  liver  are  accom- 
panied with  acute,  lancinating  pains,  considered  to  be  very  characteristic  ; and 
yet  on  perusing  our  observations  on  this  head  we  find,  on  the  one  hand,  that 
these  pains  have  been  observed  in  persons  who  had  other  affections  of  the  liver, 
and  on  the  other  hand,  we  find  that  persons  labouring  under  cancers  of  the 
liver,  with  very  little  or  no  pain,  are  almost  as  numerous  as  those  who  have 
felt  acute  pain. 

It  is  not  uncommon  to  find  after  death  cellular  adhesions  more  or  less  numer- 
ous uniting  the  liver  either  to  the  diaphragm,  or  to  the  abdominal  parietes. 
With  these  adhesions  we  think  we  may  connect  those  pains,  whether  acute, 
slight,  continued,  or  intermittent,  which  some  individuals  complain  of  in  the  right 
hypochondrium.  These  pains,  every  time  they  become  exasperated,  are  often 
accompanied  by  marked  disturbance  in  the  functions  of  the  liver,  without  the 
latter  being  itself  diseased. 

Extremely  acute  pains  are  sometimes  felt  in  the  hepatic  region,  which  cannot 
be  accounted  for  after  death  by  any  lesion  of  the  liver,  or  of  its  excretory  ducts. 
This  is  the  case  of  certain  hepatic  colics.  This  single  circumstance,  and  still 
further,  the  character  of  these  pains,  their  intermittent  nature,  the  good  state  of 
health  which  often  exists  in  the  intervals  between  them,  induce  us  to  think  that 
these  pains  principally  have  their  seat  in  the  numerous  nervous  filaments  dis- 
tributed to  the  liver,  which  arise  from  the  pneumogastric  nerve,  or  from  the 
great  sympathetic.  We  have  additional  proof  that  these  pains  belong  to  the 
liver,  because  they  are  often  accompanied  with  jaundice,  which  disappears  with 
them,  or  which  may  continue  a longer  or  shorter  time  after  them.  There  is 
nothing  astonishing  in  this  case  in  the  affection  thus  modifying  the  biliary  se- 
cretion, as  we  know  the  nervous  influence  evidently  modifies  many  other  secre- 
tions, as  that  of  the  tears,  of  the  saliva,  the  urine,  etc.  Tic-douloureux  is  also 
accompanied  with  a vitiated  secretion  of  the  buccal  glands. 

3°.  There  are  some  diseases  of  the  liver,  which  most  ordinarily  produce  but 
very  dull  pain,  or  no  pain  at  all,  as  in  several  of  its  chronic  affections  ; the  de- 
velopment of  hydatids  in  its  substance,  its  fatty  degeneration,  its  induration,  its 
different  species  of  general  or  partial  hypertrophy  (granulations,  cirrhosis,  etc.), 
in  a word,  its  atrophy,  which  also  may  be  general  or  partial.  In  this  latter 
affection  where  the  liver  forms  no  tumour,  it  may  be  anticipated  how  obscure 


310 


ANDRAL’S  MEDICAL  CLINIC. 


the  diagnosis  must  be  in  consequence  of  the  absence  of  pain.  Thus  it  can 
only  be  conjectured  from  the  existence  of  some  general  symptoms  to  be  spoken 
of  hereafter.  It  must  not,  however,  be  forgotten,  that  in  several  cases  where 
the  affection  has  become  completely  free  from  pain,  when  it  is  observed,  there 
was  a period,  towards  the  onset  of  the  disease,  where  pains  more  or  les3  acute 
existed. 

12.  The  modifications  which  the  liver  often  presents  with  respect  to  size 
may  be  detected  during  life,  if  there  be  an  increase  in  this  size  ; and  sometimes 
also  when  it  is  diminished,  this  diminution  of  size  may  be  detected  : 1st,  by 
examining  the  form  of  the  abdomen,  and  of  the  lower  part  of  the  chest  on  the 
right  side  ; 2dly,  by  the  touch  ; 3dly,  by  percussion. 

There  are  some  cases  wherein  the  eye  can  detect  the  existence  of  a tumour 
in  the  right  hypochondrium ; the  abdominal  parietes  are  raised  by  it ; and  we 
may  sometimes  distinctly  trace  the  thin  edge  of  the  liver  through  these  parietes  ; 
this  organ  sometimes  becomes  very  manifest  after  the  operation  of  paracentesis. 
The  eye  itself  is  then  sufficient  to  detect  the  existence  of  disease  of  the  liver. 
In  other  cases  the  signs  are  not  so  well  marked.  By  the  eye  we  can  only 
detect  the  existence  of  a tumour  in  either  of  the  hypochondria,  or  in  the  epigas- 
trium. But  other  signs  are  necessary  in  order  to  arrive  at  a knowledge  of  the 
nature  of  this  tumour.  In  some  patients  the  portion  of  this  viscus  concealed 
behind  the  ribs  may  have  increased  in  size  so  as  to  throw  them  out,  particularly 
at  their  cartilaginous  portion,  and  thus  produce  a singular  deformity  in  the 
inferior  and  right  side  of  the  chest.  We  then  observe  the  anterior  surface  of 
the  last  ribs  and  of  their  cartilages  become  superior,  their  upper  edge  become 
posterior,  etc.  The  last  rib  being  pushed  out  becomes  very  perceptible  to  the 
eye. 

The  touch  yields  more  and  more  varied  information  than  that  obtained  by  the 
eye.  In  several  persons  labouring  under  affections  of  the  liver,  with  increase  in 
the  size  of  this  organ,  nothing  else  is  ascertained  on  feeling  the  abdomen,  but 
unequal  resistance  on  pressing  on  both  sides  of  the  linea  alba.  Thus,  whilst  the 
abdominal  parietes  in  the  left  hypochondrium  may  be  readily  depressed,  and  the 
JiS'fiu  plunges  to  a considerable  depth  without  meeting  any  obstacle,  in  the  right 
hypochondrium,  on  the  contrary,  the  abdominal  parietes  are  tense,  as  if  a solid 
body  situate  behind  them  prevented  them  from  yielding  to  the  depressing  power 
of  the  hand.  There  are  many  cases  of  disease  of  the  liver  where  this  inequality 
of  softness  in  the  two  hypochondria  is  the  only  sign  of  the  tumefaction  of  this 
organ. 

At  other  times  it  happens  that,  in  the  right  hypochondrium,  we  can  circum- 
scribe a body  which  is  prolonged  behind  the  ribs,  and  which,  by  its  form  and  its 
situation,  seems  to  be  the  liver  in  a state  of  enlargement.  But  in  order  to 
ascertain  it  fully,  the  manner  of  practising  the  touch  is  not  indifferent.  It  is 
sometimes  sufficient  merely  to  apply  the  hand  over  the  hypochondrium,  and  to 
press  it  regularly  from  before  backwards  in  its  different  points  ; then  by  way  of 
comparison,  to  examine  by  the  touch  the  other  parts  of  the  abdomen,  and 
always  after  the  same  manner.  It  is  likewise  necessary  to  employ  the  exami- 
nation by  the  hand,  the  patient  being  placed  in  different  positions,  either  lying 
on  his  back,  or  on  either  side,  sitting  down,  or  standing  up.  Oftentimes  in  thus 
examining  with  the  hand  the  tumour  whose  presence  is  detected  cannot  be  cir- 
cumscribed, its  limits  being  undefined.  Another  process  must  then  be  employed. 
Carry  the  hand  over  the  hypochondrium,  so  placing  it,  that  all  the  fingers  being 
extended  and  approximated  to  one  another,  with  the  exception  of  the  thumb, 
the  entire  external  edge  of  the  index  finger  may  touch  the  abdominal  parietes. 
Press  the  hand  in  this  precise  direction  from  before  backwards  ; then  carry  it 
quickly  from  below  upwards,  bringing  its  ulnar  edge  close  to  the  parietes  of  the 
abdomen,  and  constantly  pressing  with  its  radial  edge  in  this  new  direction.  By 


DISEASES  OF  THE  ABDOMEN. 


311 


proceeding  in  this  way  we  may  often  succeed  in  circumscribing  accurately  the 
thin  edge  of  the  liver.  Sometimes,  again,  this  organ  presents  over  its  entire 
extent  as  far  as  is  perceptible  to  the  touch  a smooth,  uniform  surface ; some- 
times abnormal  elevations  are  detected  in  it ; whilst  sometimes  it  presents 
points  where  it  is  really  depressed,  and  as  it  were  excavated  ; it  would  appear 
that  in  these  points  it  has  undergone  a loss  of  substance. 

It  is  not  in  the  right  hypochondrium  only  that  the  liver  may  be  felt  by  the 
touch  ; there  are  scarcely  any  points  of  the  abdomen  where  its  existence  may 
not  be  detected  by  these  means.  First,  it  may  be  felt  simultaneously  in  the 
right  hypochondrium,  in  the  epigastrium,  and  in  the  left  hypochondrium. 
The  diagnosis  then  presents  but  few  difficulties ; in  fact  we  feel,  and  some- 
times see,  the  tumour  come  out,  in  a manner,  from  behind  the  ribs  on  the 
right  side,  and  extend  from  thence  over  the  points  now  mentioned.  It  may  be 
limited  to  the  epigastrium,  or  advance  more  or  less  into  the  left  hypochondrium  ; 
more  than  once  have  we  traced  its  course  thus  from  right  to  left.  The  hepatic 
tumour,  having  once  reached  the  splenic  portion  of  the  abdomen,  may  terminate 
there  in  different  ways,  either  by  forming  there  a sort  of  rounded  mass,  the  limits 
of  which  are  not  readily  found,  or  by  forming  a sort  of  tongue  with  thin  edges, 
which  may  still  be  felt  through  the  abdominal  parietes. 

The  diagnosis  becomes  more  difficult,  when  the  tumour  formed  by  the  liver 
does  not  exist  in  the  right  hypochondrium,  being  confined  to  the  epigastrium  or 
left  hypochondrium.  This  occurs  when  the  liver  is  unequally  enlarged,  and 
when  the  left  lobe  is  in  a state  of  hypertrophy,  in  which  the  right  lobe  does  not 
participate.  In  the  former  case  it  may  be  taken  for  a tumour  of  the  stomach, 
and  in  the  latter  either  for  the  same,  or  for  a tumour  of  the  spleen.  But  by  at- 
tention and  practice  one  generally  succeeds  in  distinguishing  these  different 
cases.  For  tumours  formed  by  the  stomach  very  rarely  extend  behind  the 
ribs  ; they  are  in  general  more  or  less  moveable.  The  epigastric  tumours  which 
are  formed  by  the  liver  may  be  almost  always  traced  behind  the  ribs  ; they  are 
limited  exactly  to  the  left  hypochondrium,  whilst  on  the  right  they  a,re  felt  to 
disappear  imperceptibly,  and  without  its  being  possible  to  say  where  they  ter- 
minate. They  are  in  general  much  less  moveable  than  tumours  of  the  stomach. 
This  state  of  the  digestive  functions  may  also  serve  to  throw  light  on  the  dia- 
gnosis, but  yet  only  in  a secondary  way  ; for  in  several  chronic  affections  of 
the  liver,  there  exists  at  the  same  time  gastritis,  and,  still  further,  the  liver  may, 
by  its  mere  presence  in  the  epigastrium,  compress  the  stomach,  and  embarrass 
its  functions.  With  respect  to  tumours  formed  by  the  spleen,  their  direction 
which  is  ordinarily  oblique  from  above  downwards,  and  from  left  to  right,  and 
the  point  from  which  they  commence,  may  distinguish  them  in  most  cases  from 
tumours  of  the  left  hypochondrium  formed  by  the  left  lobe  of  the  liver. 

The  liver  may  occupy  other  points  of  the  abdomen,  and  be  detected  there  by 
manual  examinations.  It  has  been  seen  to  occupy  the  umbilical  region,  the 
flanks,  to  touch  the  crest  of  the  ileum,  to  descend  even  nearly  as  far  as  the  pubes, 
and  to  occupy,  in  a word,  almost  the  entire  abdomen.  The  cases  wherein  it  is 
separated  only  one  or  two  fingers’  breadth  from  the  crest  of  the  right  ileum  are  not 
very  uncommon  ; those  wherein  it  advances  towards  the  hypogastrium  are  much 
less  common. 

Two  principal  circumstances  prevent  us  in  a considerable  number  of  cases 
from  feeling  the  tumour  formed  by  the  liver  in  one  of  the  points  just  men- 
tioned. The  first  of  these  circumstances  is  the  presence  of  a considerable 
liquid  effusion  in  the  peritoneum  ; the  second  is  the  distension  of  the  large 
intestine,  either  by  faeces  or  by  gases.  This  distension  ceasing  by  stools  na- 
tural or  artificially  brought  on,  we  begin  distinctly  to  feel  a tumour,  which  till 
then  had  been  imperceptible,  or  which  at  least  could  have  been  but  barely  sus- 
pected. 

The  liver  may  form  a tumour,  either  in  the  epigastrium,  or  in  either  of  the 


312 


ANDliAL’S  MEDICAL  CLINIC. 


hypochondria,  without  being  really  increased  in  size.  This  happens  when  an 
effusion  formed  in  the  right  pleura  is  large  enough  to  press  the  diaphragm  down- 
wards, and  at  the  same  time  the  liver,  which  then  forms  a greater  or  less  pro- 
jection below  the  ribs.  This  also  happens  when  a tumour  developed  in  the 
abdomen,  near  the  liver,  and  formed  either  at  the  expense  of  the  organs,  or  at 
the  expense  of  the  portions  of  the  peritoneum  which  separate  them,  comes  to 
occupy  the  place  usually  occupied  by  the  liver.  In  one  case,  for  instance,  an 
encysted  tumour  developed  between  the  kidney  and  the  liver,  had  caused  the 
latter  organ  to  undergo  a sort  of  oscillating  movement,  in  consequence  of  which 
the  liver  pushed  from  the  right  hypochondrium,  and  inclining  from  above  down- 
wards, from  right  to  left,  and  from  behind  forwards,  formed  during  life  a consi- 
derable projection  in  the  left  hypochondrium.  It  was  clearly  discovered  that 
the  tumour  was  formed  by  the  left  lobe  of  the  liver;  and  further,  it  was  natural 
to  think  that  this  lobe  formed  this  considerable  projection  only  because  its  volume 
was  actually  increased.  This  however  was  not  the  case,  as  the  post-mortem 
examination  proved. 

Not  only  may  tumours  of  the  stomach,  spleen,  peri-hepatic  peritoneum,  and 
gastro-hepatic  epiploon  sometimes  be  mistaken  for  tumours  connected  with  the 
liver  ; but  there  are  even  cases  where  organs  situate  at  a very  great  distance  from 
the  liver  in  their  normal  state  may,  on  becoming  swollen  and  enlarged,  approach 
the  hypochondria,  occupy  them,  and  there  form  tumours  which  appear  to  depend 
on  the  liver. 

In  a woman  labouring  under  encysted  dropsy  of  the  ovary,  the  tumour  was 
disposed  in  the  following  manner  : in  the  iliac  region  of  the  right  side  we  felt  a 
hard,  uneven,  bossilated  body;  we  traced  it  obliquely  from  below  upwards,  and 
from  right  to  left,  to  near  the  umbilicus,  where  it  ceased  to  be  perceptible. 
Above  the  umbilicus  the  abdomen  presented  its  natural  softness.  But  over  the 
extent  of  some  fingers’  breadth,  below  the  cartilaginous  edge  of  the  ribs  of  the 
left  side,  a second  tumour  existed,  formed  by  a body  which  appeared  to  be  irre- 
gularly rounded,  without  any  inequalities  on  its  surface.  This  body  appeared 
to  extend  behind  the  ribs.  In  its  form,  situation,  and  relations,  it  closely 
resembled  the  left  lobe  of  the  liver  unnaturally  enlarged.  And  such  was  the 
diagnosis  given  on  the  case,  some  time  after  the  patient’s  admission  into  the 
hospital.  The  lower  tumour  having  very  much  increased,  and  its  nature  not 
appearing  doubtful,  the  operation  of  paracentesis  was  performed,  in  which  the 
interior  of  the  tumour  was  penetrated,  which  had  been  considered  as  encysted 
dropsy  of  the  ovary.  A great  quantity  of  the  liquid  flowed  out ; the  tumour  of 
the  iliac  region  subsided;  and  at  the  same  time,  what  was  remarkajble,  the 
tumour  of  the  left  hypochondrium,  which  appeared  to  have  no  connexion  with 
the  lower  one,  changed  its  position,  and  descended  to  the  level  of  the  umbilicus. 
From  henceforward  it  ceased  to  be  considered  as  appertaining  to  the  liver;  it 
now  appeared  to  be  merely  a connexion  of  the  tumour  of  the  iliac  region,  and, 
like  it,  to  appertain  to  the  dropsy  of  the  ovary,  of  which  it  seemed  to  form  the 
seat.  Butin  this  case  why  had  it  occupied  till  then  the  left  hypochondrium,  and 
why  had  it  suddenly  changed  its  position  after  being  punctured?  This  might 
be  explained.  It  might  be  supposed,  in  fact,  that  before  this  operation  the 
superior  part  of  the  tumour  of  the  ovary  was  kept  elevated,  and,  as  it  were, 
supported,  in  one  of  the  hypochondria  by  the  inferior  portion,  which  was  dis- 
tended with  a great  quantity  of  liquid ; the  latter  having  been  let  out,  the 
tumour  of  the  hypochondrium  must  necessarily  change  its  place.  The  patient 
died,  and  an  opportunity  was  afforded  of  verifying  the  diagnosis  : the  following 
lesions  were  found  at  th e post-mortem  examination  : — 

The  peritoneum  of  the  abdominal  parietes  was  found  united  to  that  covering 
the  viscera  by  very  close  adhesions  ; immediately  behind  these  parietes  an 
enormous  tumour  was  found,  which  filled  the  hypogastrium,  umbilicus,  the  two 
iliac  regions,  and  the  two  flanks,  the  entire  of  the  left  hypochondrium,  which  it 


DISEASES  OF  THE  ABDOMEN. 


313 


occupied  as  far  as  the  level  of  the  fifth  rib,  and  a part  of  the  epigastrium  and 
right  hypochondrium  ; it  pressed  the  liver  up  very  much,  which  ascended  as  far 
as  the  fourth  rib,  and  the  stomach,  which  was  found  on  a level  with  this  viscus. 
Before  it  the  scirrhous  epiploon  was  extended  ; in  the  left  flank  the  descending 
colon  was  perceived,  and  some  convolutions  of  the  small  intestine,  the  principal 
part  of  which  was  concealed  by  the  tumour.  It  was  easily  detached  from  the 
parts  in  connexion  with  it,  and  to  which  it  was  united  only  by  cellular  adhe- 
sions. Inferiorly  it  was  connected  with  the  uterus  by  the  right  Fallopian  tube, 
and  the  ovarian  ligament  of  the  same  side.  No  trace  of  the  right  ovary  could  be 
found  : the  left  was  intact.  It  presented,  as  it  were,  three  distinct  parts  ; one 
situate  in  the  left  hypochondrium,  and  in  the  epigastrium,  seemed  to  be  formed 
of  a hard  and  solid  tissue  ; the  other,  situate  in  the  flank  and  right  iliac  fossa, 
presented  the  same  appearance.  Lastly,  the  portion  which  occupied  the  umbili- 
cus and  hypogastrium,  and  which  connected  the  two  preceding,  was  soft  and 
of  a shining  appearance,  and  seemed  to  consist  of  a pouch  full  of  liquid  ; on 
making  an  incision  into  this  third  portion,  a great  quantity  of  a greyish  puru- 
lent liquid  was  observed  to  escape.  The  cavity  containing  it  might  contain  at 
least  the  head  of  a foetus.  On  the  inner  surface  of  its  parietes  there  existed  from 
eight  to  ten  tumours,  which  were  on  an  average  the  size  of  an  orange.  When 
cut  into  they  all  presented  a similar  tissue — namely,  myriads  of  fine  filaments, 
of  a red  or  white  colour,  which  crossed  each  other  in  a thousand  different  direc- 
tions, leaving  between  them  areolae  filled  with  a liquid  which  was  colourless 
in  some,  red  or  brownish  in  others,  and  very  much  resembling  in  consistence 
and  tenacity  the  mucus  of  the  nasal  fossae.  The  largest  of  the  areolae  might 
hold  a small  filbert;  the  smallest  could  scarcely  contain  the  head  of  a moderate 
sized  pin.  It  would  be  difficult,  I think,  to  refer  this  tissue  to  any  of  those 
hitherto  described.  In  some  parts  it  resembled  softened  scirrhus,  in  others 
accidental  erectile  tissue  ; the  latter  parts  were  very  like  a portion  of  spleen 
emptied  of  blood  and  subjected  to  repeated  washing.  The  other  parts  of  the 
tumour  consisted  of  a similar  tissue.  It  was  enveloped  through  its  entire 
extent  by  a thick,  evidently  fibrous  membrane.  Its  external  surface  was 
covered  by  the  peritoneum  ; its  internal  surface,  when  examined  in  the  great 
pouch,  was  wrinkled,  of  a red  colour  like  wine  lees,  lined  with  an  albuminous 
membraniform  layer,  resembling  that  which  lines  the  parietes  of  pulmonary 
caverns.  It  presented,  moreover,  a considerable  number  of  small  white  granu- 
lations, about  the  size  of  a grain  of  millet,  which  resembled  very  much  the  granu- 
lations raised  on  the  internal  surface  of  several  hydatids,  known  by  the  name  of 
acephalo-cysts. 

This  membrane  might  be  easily  divided  into  a great  number  of  laminae  placed 
one  over  the  other.  In  some  points  the  innermost  laminae  presented  a deep 
black  colour,  under  the  form  of  broad  patches  or  long  striae. 

The  great  epiploon,  as  also  the  mesentery,  were  transformed  into  thick  can- 
cerous masses  ; when  cut  into,  they  presented  in  several  points  a white,  opaque 
tissue  traversed  by  numerous  red  lines  (encephaloid  tissue  in  the  state  of  crudity). 
In  other  points  nothing  was  found  but  a sort  of  reddish  detritus,  and  even  red 
sanguineous  effusions  (softened  encephaloid  tissue).  In  other  parts,  with  the 
white  and  hard  tissue  now  described,  a yellowish  and  friable  tissue  was  mixed, 
which  readily  crumbled  under  the  finger,  like  sulphate  of  lime  saturated  with 
water  (tuberculous  matter). 

The  interior  of  the  liver  presented  three  or  four  cancerous  masses  formed  by 
the  encephaloid  tissue  still  crude,  being  each  nearly  the  size  of  a filbert.  The 
lungs  on  either  side  descended  only  as  far  as  the  level  of  the  fourth  rib.  The 
heart  was  healthy,  and  was  filled  with  liquid  black  blood. 

13.  If,  after  having  passed  in  review  the  different-varieties  of  tumours  per- 
ceptible to  the  touch  which  the  liver  may  present,  we  set  about  enquiring  what 
27 


314 


ANDIIAL’S  MEDICAL  CLINIC. 


are  the  diseases  of  the  liver  in  which  these  tumours  are  chiefly  observed,  we 
shall  not  be  able  to  lay  down  any  constant  rule  on  this  point.  On  the  one 
hand,  there  is  scarcely  any  one  in  which  the  form  of  the  liver  may  not  be 
modified,  so  as  to  give  rise  to  a tumour  discoverable  during  life ; and  on  the 
other  hand,  all  the  affections  of  the  liver  may  arise,  become  developed,  run 
through  their  different  stages,  without  the  organ  increasing  sufficiently  to  form 
a tumour. 

In  the  cases  of  simple  sanguineous  congestion,  whether  active  and  produced 
by  a vital  stimulus,  or  connected  with  a mechanical  obstacle  to  the  circulation, 
the  liver  may  be  so  tumefied  as  to  be  felt  in  the  hypochondrium  and  epigastrium. 
This  tumefaction  is  sometimes  very  rapid ; oftentimes,  also,  it  is  observed  to 
disappear  with  as  much  rapidity  as  it  had  formed,  either  spontaneously,  or  after 
bloodletting  carried  to  a greater  or  less  extent.  There  are  some  patients  in 
whom  the  right  hypochondrium  becomes  thus  tumefied,  it  then  resumes  its 
natural  softness,  and  this  occurs  several  times.  Such  intermittent  tumefactions 
of  the  liver  are  principally  observed  during  the  course  of  certain  organic  affec- 
tions of  the  heart.  In  most  cases  they  are  not  accompanied  with  any  other 
disturbance  of  the  functions  of  the  liver  ; there  is  neither  any  pain  observed, 
nor  trace  of  jaundice.  Sometimes,  however,  the  patients  complain  of  a painful 
sensation,  a sort  of  weight  towards  the  hypochondrium,  and  a slight  yellow  tint 
is  spread  over  the  skin.  After  having  thus  appeared  and  disappeared  several 
times,  the  tumefaction  of  the  liver  may  remain  permanent,  and  that,  which  at 
first  was  but  a temporary  sanguineous  congestion,  may  become  imperceptibly  a 
serious  alteration  of  texture. 

It  would  be  very  difficult,  in  my  opinion,  to  draw  an  exact  line  of  demarcation 
in  the  liver,  as  in  every  other  organ,  between  the  highest  degree  of  simple  active 
congestion  and  inflammation  properly  so  called.  The  latter  may  exist  either  in 
the  acute,  or  in  the  chronic  state,  without  producing  any  kind  of  tumour,  and  if, 
at  the  same  time,  no  pain  exists,  the  diagnosis  will  be  very  obscure.  But  in  a 
great  number  of  cases,  acute  hepatitis  brings  on  tumefaction  of  the  liver,  and  the 
latter  may  then  be  felt  in  the  hypochondrium.  This  tumefaction  may  exist,  and 
be  formed  very  rapidly  with  or  without  pain,  with  or  without  jaundice.  Some- 
times it  lasts  only  a few  days,  and  disappears  ; in  other  cases  it  lasts  for  several 
weeks,  and  even  for  several  months,  and  then  disappears.  It  must  be  admitted 
that  in  such  cases  there  was  only  engorgement  of  the  liver,  without  any  real 
alteration  of  its  nutrition.  This  tumefaction,  by  inflammatory  engorgement  of 
the  organ,  may  be  formed  rapidly,  and  may  then  have  remained  stationary,  or 
else  it  is  developed  only  in  an  imperceptible  manner.  In  the  former  case  the 
hepatitis,  acute  at  its  onset,  passes  only  secondarily  into  the  chronic  state  : in 
the  second  case  it  is  primarily  chronic.  These  different  engorgements  of  the 
liver  deserve  attention  so  much  the  more,  as  they  are  unquestionably  the  very 
commencement  of  a considerable  number  of  its  organic  affections,  whether 
hypertrophy  and  induration  of  its  substance,  or  cancerous  degeneration,  etc.  It 
is  these  sanguineous  congestions,  acute  or  chronic,  without  any  other  alteration, 
which  may  be  combated  with  advantage  by  different  therapeutic  means,  whilst 
these  same  means  appear  to  be  generally  ineffectual  in  treating  most  of  the 
alterations  of  texture,  of  which  inflammatory  engorgement  of  the  liver  has  also 
been  the  commencement.  It  is  from  not  having  sufficiently  distinguished  these 
different  cases  that  the  same  remedies  employed  successfully  for  the  purpose  of 
removing  several  tumours  of  the  liver,  have  completely  failed  in  other  cases 
which  were  apparently  identical. 

In  these  cases  of  simple  engorgement*  of  the  liver,  the  tumour  which  it  forms 

* The  structure  of  the  liver,  such  as  has  been  described,  accounts  for  the  readiness  with 
which  these  engorgements  may  take  place,  and  also  for  their  frequency  ; it  also  accounts  for 
the  rapid  increase  in  size  which  the  organ  may  take  on. 


DISEASES  OF  THE  ABDOMEN. 


315 


presents  a smooth  surface,  without  projections  or  depressions.  The  same  may 
happen  with  different  alterations  of  texture.  But  further,  in  this  latter  case, 
another  matter  is  often  observed.  Thus,  in  the  case  where  the  tissue  of  the 
liver  is  indurated,  it  often  presents  on  its  surface  numerous  inequalities,  which 
arise  from  its  not  being  equally  hypertrophied  in  all  its  points.  When  cancerous 
masses  are  developed  in  the  hepatic  parenchyma,  manual  examination  detects, 
more  frequently  than  in  any  other  affection  of  the  liver,  numerous  knobs  which 
raise  the  abdominal  parietes.  But  what  is  very  remarkable,  it  happens  occasion- 
ally that  after  a longer  or  shorter  time  these  knobs  disappear,  the  place  which 
they  occupied  becomes  actually  a cavity,  and  instead  of  an  elevation,  examina- 
tion by  the  touch  detects  a depression.  This  indicates  that  the  disease  is  taking 
a fatal  course  ; where  a projection  is  found  which  has  succeeded  to  an  elevation, 
we  may  be  satisfied  that  a cancerous  mass  has  undergone  considerable  soft- 
ening. 

Immense  abscesses  may  form  in  the  liver,  without  their  being  accompanied 
with  any  tumefaction  of  the  organ  perceptible  to  the  touch.  At  other  times, 
there  may  exist  a tumour  in  the  hypochondrium,  but  this  tumour  presents  no 
other  characters  than  those  which  belong  to  simple  sanguineous  engorgement  of 
the  liver.  This  I believe  to  be  the  most  common  case.  Under  other  circum- 
stances the  abscess  being  situated  very  superficially  has  for  its  parietes  anteriorly 
merely  a very  thin  layer  of  the  substance  of  the  liver,  which  is  in  immediate 
contact  with  the  abdominal  parietes.  Then  by  pressure  judiciously  made  we 
may  detect  behind  these  parietes  the  existence  of  a cavity  full  of  liquid;  around 
this  there  is  often  felt  a hard  body,  which  is  nothing  but  the  portion  of  paren- 
chyma surrounding  the  abscess. 

The  hydatids  developed  in  the  liver  are  contained  there  in  a sac  with  fibrous 
parietes,  which  often  forms  a prominence  on  the  exterior  of  the  organ,  and 
which  may  be  detected  by  the  touch.  The  tumour  resulting  from  this  usually 
raises  a point  of  the  abdominal  parietes,  and  is  perceptible  to  the  eye.  If  we 
examine  it  with  the  hand,  or  press  it  in  different  directions,  we  are  struck  with 
its  extreme  resistance,  and  its  great  elasticity ; this  is  conformable  with  its 
anatomical  structure.  These  external  characters  seem  to  me  so  marked,  that 
they  may  cause  it  to  be  considered  at  least  as  very  probable,  that  the  tumour 
perceptible  to  the  sight  and  touch  in  the  right  hypochondrium,  and  which  seems 
to  be  continued  behind  the  ribs,  is  owing  to  the  development  of  an  hydatiferous 
sac.  This  species  of  tumour,  when  it  is  exempt  from  all  complication,  may 
exist  for  a long  time  without  producing  pain,  or  interfering  considerably  with 
the  functions  of  the  liver;  without  occasioning  any  sympathetic  disturbance  in 
the  system,  lighting  up  fever,  or  at  all  changing  the  general  functions  of  nutri- 
tion. These  circumstances  may  also  serve  to  throw  light  on  the  diagnosis. 

I have  observed  a remarkable  termination  of  these  tumours  in  the  Charite  ; 
namely,  the  change  of  the  hydatiferous  sac  into  a purulent  deposition  ( foyer ). 
The  patient  had  presented  for  a long  time  near  the  epigastrium,  immediately 
beneath  the  cartilaginous  edge  of  the  right  ribs,  a round  tumour,  extremely 
elastic,  about  the  size  of  an  orange,  without  pain,  or  change  of  colour  in  the  skin, 
the  general  health  being  still  preserved.  This  tumour  appeared  to  us  to  be  a 
sac  of  hydatids.  After  some  time  it  became  the  seat  of  a pain  at  first  not  very 
acute,  which  subsequently  became  lancinating  at  intervals  ; the  features  became 
changed,  fever  set  in,  considerable  emaciation  took  place  after  a little  time,  pro- 
fuse diarrhoea  supervened,  but  a considerable  time  after  the  appearance  of  the 
different  symptoms  now  described,  and  ultimately  the  patient  died. 

On  opening  the  body  we  found  on  the  upper  surface  of  the  left  lobe  of  the 
liver  a tumour  corresponding  to  the  point  where  it  had  been  felt  during  life 
through  the  abdominal  parietes.  This  tumour  having  been  cut  into,  a great 
quantity  of  greenish,  inodorous  pus  flowed  from  it,  in  the  midst  of  which  burst 


316 


ANDRAL’S  MEDICAL  CLINIC. 


and  torn  hydatids  were  observed  to  float.  Almost  the  entire  left  lobe  of  the 
liver  was  taken  up  by  an  enormous  cavity,  in  which  were  contained  the  pus  and 
hydatids  which  had  escaped  on  making  the  incision. 

We  thought  it  should  be  admitted  that  the  tumour  appreciable  during  life  had 
at  first  consisted  of  a simple  sac  of  hydatids  ; this  sac  subsequently  became 
inflamed,  its  internal  surface,  instead  of  exhaling  serum,  had  secreted  pus,  and 
then  only  that  group  of  alarming  symptoms  appeared,  in  the  midst  of  which  the 
patient  died.  The  state  of  the  hydatids  was  remarkable.  It  is  probable  that 
they  had  ceased  to  live,  when  the  pus  began  to  surround  them.  Another  time  I 
found  the  debris  of  hydatids  in  the  midst  of  an  encysted  abscess  of  the  perito- 
neum ; and  now  that  I am  on  this  subject  I recollect  that  in  a previous  part  of  this 
work  I cited  cases,  where  tuberculous  matter  had  been  deposited  around  hyda- 
tids, and  had  by  little  and  little  taken  possession  of  the  cavity  primarily  occu- 
pied by  these  animals. 

Other  tumours  occupying  the  left  hypochondrium  depend  on  different  altera- 
tions of  the  gall-bladder  ; we  shall  consider  them  in  another  place. 

14.  Percussion  of  the  inferior  and  right  side  of  the  chest  must  not  be  neglected 
among  the  means  to  be  employed  for  ascertaining  the  size  of  the  liver.  There 
are  cases  where,  at  the  same  time  that  this  organ  forms  a tumour  in  the  right 
hypochondrium,  in  the  epigastrium,  or  in  other  points  of  the  abdomen,  it  forcibly 
presses  up  the  diaphragm,  ascends  higher  than  usual  into  the  thoracic  cavity, 
comes  into  closer  apposition  with  the  ribs,  and  no  longer  allows  the  lungs  to 
become  interposed  between  it  and  them.  Then  the  sound  of  the  thoracic  parie- 
tes,  over  all  their  lower  and  right  portion,  is  more  completely  dull,  and  more 
extensively  so  than  usual ; sometimes  even  the  left  lobe  of  the  liver  becoming 
more  developed,  comes  to  apply  itself  to  the  last  ribs  of  the  left  side,  and  there 
produces  a sound  similar  to  that  frequently  produced  by  the  enlarged  spleen  in 
this  same  part.  It  must  not  be  forgotten  that  the  liver  may  thus  be  consider- 
ably enlarged,  either  upwards,  towards  the  chest,  or  laterally  in  its  left  portion, 
without  passing  the  edges  of  the  ribs,  so  that  then  the  increase  of  the  dull  sound 
in  the  points  just  mentioned  is  the  only  circumstance  which  can  detect  the  in- 
crease in  the  size  of  the  liver. 

At  other  times,  on  the  contrary,  the  sound  of  the  lower  part  of  the  thorax  on 
the  right  side  is  clearer  than  usual.  This  happens  in  cases  where  there  is 
diminution  in  the  size  of  the  liver,  and  this  sort  of  information  is  not  to  be 
neglected,  when  other  signs  incline  ns  to  suspect  the  existence  of  such  a lesion. 

15.  It  would  seem  that  the  liquid  secreted  by  the  liver  should  be  changed 
when  there  is  lesion  of  this  organ.  However,  this  is  not  always  the  case. 
There  are  some  cases  where  the  liver  having  been  for  a considerable  time 
seriously  diseased,  the  bile  does  not  present  either  in  quantity  or  quality  any 
modification  appreciable  at  least  by  our  senses.  On  the  other  hand  we  some- 
times find  the  bile  perceptibly  changed,  though  the  lesion  of  the  liver  which 
has  occasioned  it  entirely  escape  us.  Oftentimes,  for  instance,  I have  met  in 
the  gall-bladder  nothing  but  an  aqueous  or  albuminous  liquid,  with  a slight 
yellowish  tint;  the  inner  surface  of  the  biliary  ducts  was  not  of  a yellow  tinge 
as  usual,  they  contained  a little  liquid  like  that  of  the  gall-bladder.  I found 
this  state  of  the  bile  in  the  three  following  cases  : — 1st,  when  there  was  fatty 
degeneration  of  the  liver,  as  if  the  secretion  of  bile  was  then  succeeded  by  the 
secretion  of  fatty  matter  ; 2d,  in  some  cases  of  atrophy  of  the  liver  carried  to  an 
extreme  degree;  3d,  in  some  other  cases  where  there  was  hypertrophy,  indu- 
ration of  the  hepatic  parenchyma,  a development  of  cirrhosis  or  of  red  granu- 
lations. It  is  probable  that  in  these  different  kinds  of  organic  lesions  the  ana- 
tomical element  engaged  in  the  secretion  of  bile  becomes  involved.  The  bile 
seems  to  me  to  deviate  much  less  frequently  from  its  natural  state,  at  least  to 
all  appearance,  in  those  cases  where  accidental  productions  — as  pus,  cancer, 


DISEASES  OF  THE  ABDOMEN. 


317 


tubercle,  hydatids  — existed  in  the  liver,  than  in  cases  even  where  these  pro- 
ductions occupied  more  than  half,  and  even  three-fourths  of  the  entire  substance 
of  the  liver.  On  the  contrary,  in  several  individuals  who  died  of  different  acute 
or  chronic  diseases  unconnected  with  the  biliary  apparatus,  and  whose  liver 
seemed  to  be  in  the  normal  state,  I have  found  this  same  serous  bile  both  in  the 
gall-bladder  and  in  the  principal  ducts  ; it  seemed  to  consist  merely  of  water, 
albumen,  and  a small  quantity  of  yellow  colouring  matter.  The  knowledge  of 
these  facts  I consider  not  devoid  of  importance.  It  tends  to  confirm  an  opinion 
which  in  England  more  particularly  has  at  the  present  day  numerous  partisans, 
and  according  to  which  a great  number  of  derangements  of  digestion  are  con- 
sidered as  depending  on  a vitiated  secretion  of  bile.  It  is  because  the  latter, 
they  say,  no  longer  flows  into  the  duodenum,  or  enters  it  in  a very  altered  state, 
that  several  individuals  experience — 1st,  a change  in  the  number  and  qualities 
of  the  stools,  which  are  scanty,  devoid  of  colour,  of  too  great  consistence,  etc. ; 
2d,  probably  imperfect  chylification,  and  consequently  bad  nutrition,  marasmus, 
etc.  This  opinion,  I think,  can  no  longer  be  regarded  as  a mere  hypothesis, 
the  moment  it  is  proved  that  in  a certain  number  of  cases  the  bile  is  really 
changed  in  its  qualities.  Now  this  follows  from  the  facts  just  cited.  But  this 
almost  total  change  of  the  bile  into  water  and  albumen  is  not  probably  the  only 
alteration  which  it  may  undergo,  it  is  only  the  most  obvious.  This  is  at  least 
certain,  that  in  dead  bodies  we  find  the  greatest  differences  in  the  appearance  of 
the  bile  of  the  gall-bladder,  with  respect  to  its  colour,  which  varies  from  a bright 
yellow  to  the  deepest  black,  with  respect  to  its  consistence,  which  presents  so 
many  degrees,  from  that  wherein  it  flows  like  water,  to  that  where  it  is  like 
very  thick  syrup,  and  in  which  at  length  it  becomes  solidified.  There  are 
some  species  of  bile,  which,  when  brought  into  contact  with  the  skin,  excite  in 
it  a disagreeable  sensation  of  acrid  heat ; we  may  here  recollect  the  experiments 
of  Morgagni,  who  having  placed  some  bile  collected  from  different  bodies  in 
the  cellular  tissue  of  several  animals,  found  that  in  some  cases  it  acted  merely 
as  a foreign  body  where  it  was  deposited,  and  that  no  bad  consequences  resulted 
from  its  absorption,  whilst  in  other  cases  it  produced  an  extremely  deleterious 
effect.  It  would  be  well  that  these  experiments  were  repeated  and  followed 
up.  We  know  so  little  as  to  how  the  bile  acts  in.  aiding  the  process  of  diges- 
tion, that  it  is  impossible  for  us  to  foresee  what  sort  of  influence  a change  in 
the  qualities  of  the  bile,  in  the  proportions  or  nature  of  its  elements,  can  pro- 
duce in  the  latter  function.  A modification  which  appears  to  us  very  con- 
siderable has  probably  but  little  influence  ; another  which  appears  to  us  less  im- 
portant, is  probably  of  much  greater  importance  in  perfecting  the  process  of 
digestion. 

These  facts  being  laid  down,  is  it  in  the  power  of  art  to  restore  the  secretion 
of  bile  to  its  perfect  state  ; and  for  this  purpose  what  means  are  to  be  employed  ? 
It  should  be  remarked,  that  in  many  cases  where  the  appearance  of  the  bile 
found  in  the  dead  body  no  longer  seems  to  be  natural,  the  liver  itself  is  exempt 
from  all  appreciable  change  ; it  seems  merely  that  in  consequence  of  some 
latent  change  in  its  vital  properties,  or  in  its  molecular  structure,  it  has  lost  the 
power  of  separating  from  the  blood  the  elements  of  the  bile  in  their  ordinary 
proportions.  English  physicians  say  that  they  restore  this  power  to  the  liver, 
and  consequently  that  they  re-establish  the  course  of  the  bile,  1st,  by  irritating 
the  intestinal  mucous  membrane  by  suitable  purgatives  ; 2dly,  by  the  use  of 
calomel,  which,  according  to  them,  exercises  a specific  action  on  the  secretion 
of  the  liver*  In  this  way,  they  say,  they  bring  about  regularity  in  the  alvine 
evacuations,  they  restore  depraved  digestion,  bring  back  health  and  flesh  to  the 
patient*  etc.  Thus  these  same  functional  disturbances,  which,  in  the  school  oft 
M.  Broussais,  are  considered  as  the  result  of  different  shades  of  gastro-enteritis, 
are  elsewhere  looked  on  as  connected  with  a vitiated  secretion  of  bile  ; they  are 
27* 


318 


ANDRAL’S  MEDICAL  CLINIC. 


treated  with  advantage,  they  say,  by  means  which  should  necessarily  aggravate 
the  gastro-enteritis,  if  it  did  exist.  The  conviction  of  English  physicians,  with 
respect  to  the  soundness  of  their  theory  and  the  efficacy  of  their  practice,  is  so 
strong,  thai  in  my  opinion  every  reasonable  mind  has  some  grounds  for  doubt, 
and  consequently  for  examination  on  this  point.  If  any  one  should  wish  to 
solve  this  question  before  having  experimented,  he  would,  I think,  find  himself 
very  much  embarrassed.  And  with  respect  to  theory,  that  of  the  physicians  of 
Great  Britain  rests  on  physiological  ideas  as  sound  and  as  defensible  as  the  theory 
put  forward  by  M.  Broussais.  With  respect  to  pathological  anatomy,  it  cannot 
afford  any  solution  of  the  question  ; for  it  points  out  very  perceptible  alterations 
in  the  qualities  of  the  bile  as  clearly  as  it  detects  intestinal  inflammations. 
Shall  we  calculate,  in  fine,  the  success  of  the  two  therapeutic  methods  ? the 
difficulty  will  only  be  increased  : for  in  England  as  many  books  have  been 
written,  as  many  cases  have  been  cited,  in  favour  of  calomel,  and  of  different 
purgatives  for  the  removal  of  derangements  of  the  digestive  functions,  as  there 
have  been  facts  published  in  France  in  favour  of  the  employment  of  antiphlo- 
gistics  under  the  same  circumstances.  In  my  own  opinion,  I think  if  we  were 
to  institute  an  experimental  study  of  these  two  methods,  for  the  purpose  of 
comparing  them,  we  should  arrive  at  this  conclusion,  that  each  may  be,  and 
must  be,  employed  according  to  the  nature  of  the  case.  I can  positively  state 
on  this  subject  that  I have  often  seen  the  employment  of  purgatives  rapidly  re- 
move certain  disturbances  of  digestion,  characterized  particularly  by  anorexia 
or  great  irregularity  of  the  appetite,  by  a sense  of  weight  in  the  abdomen,  which 
continued  for  a considerable  time  after  taking  food  into  the  stomach,  by  trouble- 
some borborygmi,  by  alvine  evacuations  alternately  too  frequent  and  too  few. 
There  was  at  the  same  time  an  habitual  feeling  of  general  distress,  a state  of 
physical  and  moral  languor,  yellowness  of  the  face,  dulness  of  the  eyes,  and 
foul  tongue.  The  cases  of  this  kind,  where  I saw  purgatives  succeed,  are  too 
numerous  for  me  to  consider  them  as  exceptions.  In  fact,  the  utility  of  pur- 
gatives appears  to  me  satisfactorily  proved  in  certain  morbid  states  of  the  diges- 
tive passages,  which,  for  that  very  reason,  I do  think  should  not  be  referred  to 
an  inflammatory  state.  In  theory,  the  advantages  of  such  treatment  might  be 
accounted  for  by  a vitiated  secretion  either  of  bile  or  of  intestinal  mucus.  No 
doubt  there  is  then  some  alteration  in  the  secreting  organ.  But  when  it  is 
affirmed  that  this  alteration  is  necessarily  an  irritation,  is  not  that  going  beyond 
the  strict  observation  of  facts  ? 

The  modifications  in  the  qualities  of  the  bile  now  under  consideration  are 
not  the  only  alterations  of  this  liquid  which  I have  discovered  in  the  dead  body. 
One  circumstance  has  struck  me  particularly  in  a considerable  number  of  autop- 
sies : that  is,  the  prodigious  quantity  of  bile  which  fills  the  intestinal  canal  in 
some  individuals  who  during  life  had  profuse  diarrhoea.  With  respect  to  the 
liver  it  presents  no  appreciable  alteration,  only  it  is  gorged  with  bile.  The 
intestinal  canal  is  sometimes  seriously  affected,  its  mucous  membrane  is  inflamed, 
and  ulcerated  ; sometimes,  on  the  contrary,  it  presents  no  other  appreciable 
lesion,  except  slight  injection  of  the  vessels  which  pass  over  the  mucous  mem- 
brane or  beneath  it ; so  that  if,  in  the  first  case,  it  may  be  said,  with  M.  Brous- 
sais, that  the  bilious  flux  has  been  consecutive  on  intestinal  irritation,  this  con- 
nexion is  no  longer  equally  manifest  in  the  second  case.  If  an  appeal  be  made 
to  individual  sensibility — if  it  be  said  that  the  irritation  primarily  fixed  on  the 
intestine  has  disappeared  from  the  latter,  and  passed  by  metastasis  to  the  liver, 
in  my  opinion  that  is  but  evading  the  objection  by  an  hypothesis  ; and,  besides, 
might  it  not  as  well  be  maintained  that  the  vascular  injection,  found  in  some 
points  of  the  intestines,  far  from  being  a trace  of  primary  inflammation  which 
occasioned  the  flux,  is,  on  the  contrary,  an  effect  of  the  latter  ? Is  it  not,  in 
fact,  very  possible  that  the  excessive  quantity  of  bile,  which  in  a given  time  is 


DISEASES  OF  TIIE  ABDOMEN. 


319 


brought  in  contact  with  the  intestinal  mucous  membrane,  becomes  a source  of 
irritation  to  this  membrane  ? There  is  no  doubt  but  that  a moderate  excitement 
of  the  digestive  canal — such  as  that,  for  instance,  produced  by  a mild  purgative 
— is  oftentimes  sufficient  to  occasion  a very  copious  flow  of  bile.  Might  not 
this  effect,  which  is  often  occasioned  by  purgatives,  become  of  great  advantage 
in  certain  morbid  states  of  the  system  ? if  we  see  several  diseases  become 
resolved  at  the  same  time  that  a fluxion  is  set  up  on  the  skin,  on  the  kidneys, 
or  on  the  salivary  glands,  why  might  not  this  same  process,  when  setup  on  the 
liver,  also  possess  its  advantages  in  certain  cases  ? Why  might  it  not  be  excited 
artificially,  as  perspiration,  the  urine,  and  salivation  are  excited? 

16.  Whether  the  bile  continues  to  flow  into  the  intestine,  or  ceases  to  do  so, 
we  observe  in  a considerable  number  of  liver  affections,  and  even  in  certain  cases 
where  no  real  disease  of  this  organ  is  discovered,  the  different  internal  and 
external  tissues  assume  a yellow  colour,  which  presents  different  shades  ; the 
result  of  this  is  jaundice,  a disease,  the  nature  and  causes  of  which  appear  to 
me  to  be  still  very  obscure  ; the  following  facts  and  remarks  will  probably  not 
be  devoid  of  utility  in  throwing  some  light  on  its  history.  Let  us  first  ascertain 
the  state  of  the  liver  in  jaundice. 

There  is  in  the  biliary  apparatus  but  one  lesion  uniformly  connected  with  the 
existence  of  jaund ice,  namely,  obstruction  of  the  ductus  hepaticus  or  chole- 
dochus.  I merely  refer  to  it  here,  before  I point  out  its  causes  and  principal 
varieties. 

At  other  times  the  biliary  ducts  are  found  quite  free  after  death;  and,  during 
life,  the  nature  of  the  stools  did  not  admit  of  a doubt  but  they  were  equally 
free.  However,  there  is  jaundice,  and  to  account  for  it  we  find  different  affec- 
tions of  the  liver.  But  here  we  can  no  longer  lay  down  a constant  rule,  as  in 
the  preceding  case.  For,  1st,  all  may  be  equally  accompanied  with  jaundice, 
whether  simple  sanguineous  engorgement  of  the  liver,  or  the  different  degrees 
of  hypertrophy  and  atrophy  of  its  two  substances,  or  of  only  one  of  them,  or  its 
softness,  or  its  induration,  or  its  suppuration,  or  its  cancerous  or  tuberculous 
degeneration,  etc. ; 2dly,  it  cannot  be  said  that  one  of  these  affections  coincides 
more  frequently  with  jaundice  than  the  others;  3dly,  they  have  all  been  seen 
to  exist  without  jaundice.  The  latter,  therefore,  is  not  the  necessary  conse- 
quence of  any  of  them  ; other  conditions  are  necessary  in  order  that  it  may 
appear. 

In  some  icteric  patients  the  liver  and  its  appendages  are  exempt  from  all 
appreciable  alterations  ; but  lesions  are  found  in  organs  whose  irritation  might 
extend  to  the  liver,  either  by  continuity  or  contiguity  of  tissue,  or  by  sympathy. 
I have  ascertained  the  existence  chiefly  of  the  three  following  lesions:  1st,  of 
acute  or  chronic  duodenitis  in  different  degrees  ; 2d,  of  inflammation  of  the 
diaphragmatic  pleura  of  the  right  side;  3d,  of  inflammation  of  the  brain  or  of 
its  membranes.  This  third  species  of  lesion  coincides  much  more  rarely  than 
the  two  former. 

Lastly,  in  several  eases  of  jaundice  no  alteration  is  found  either  in  the  liver, 
or  in  its  appendages,  or  in  the  organs,  which,  by  their  situation  or  their  nature, 
are  capable  of  exercising  any  influence  on  the  hepatic  system.  Among  the  indi- 
viduals who  were  in  this  case,  there  were  some  in  whom  the  primary  disease 
had  been  jaundice.  They  had  become  yellow  without  having  experienced  any 
other  morbid  symptom.  This  yellowishness  lasted  in  them  from  eight  days  to 
a month,  when  another  disease  suddenly  carried  them  off.  I have  seen  three 
cases  of  this  kind  ; in  the  first  death  was  the  result  of  cerebral  hemorrhage  ; in 
the  second,  it  was  owing  to  supeF-acute  peritonitis  ; and, in  the  third,  death  took 
place  suddenly,  without  the  post-mortem  examination  presenting  any  lesion 
which  could  account  for  it.  in  two  of  these  cases  the  total  absence  cf  colour 
in  the  stools  showed  that  the  bile  no  longer  reached  the  duodenum  ; in  the 
third  case,  the  alvine  evacuations  were  constantly  yellow. 


320 


ANDRAL’S  MEDICAL  CLINIC. 


If  we  now  inquire  into  the  circumstances  amidst  which  we  observe  jaundice 
to  appear  during  life,  and  which  may  have  some  influence  on  its  production,  we 
shall  find  principally  the  following  : 

1st.  Several  acute  or  chronic  affections  of  the  liver,  indicated  by  different 
orders  of  symptoms  ; sometimes  jaundice  prevails  for  the  entire  duration  of  these 
affections,  sometimes  it  accompanies  only  one  of  the  stages  of  their  existence. 

2dly.  An  acute  or  chronic  gastro-enteritis. 

3dly.  No  previous  disease  whatever;  but  a strong  mental  emotion,  a great 
fright,  a violent  fit  of  anger,  etc.  The  appearance  of  jaundice  is  then  often 
instantaneous.  What  is  the  cause  of  it  then  ? has1  the  mental  emotion  occa- 
sioned duodenitis  ? that,  to  say  the  least  of  it,  is  extremely  doubtful ; and  I 
should  rather  feel  inclined  to  admit  that  the  cause  of  jaundice  should  then  be 
placed  in  the  nervous  plexus,  so  remarkable  both  for  its  size  and  for  its  double 
origin  in  the  nervous  centres  of  animal  and  organic  life,  which  enters  into  the 
liver  with  the  vessels,  and  with  them  is  distributed  through  the  organ.  Who 
knows  whether  the  sudden  modification  which  this  plexus  may  undergo  in  its 
functions,  after  a mental  impression,  may  not  have  a powerful  influence  on  the 
secretion  of  bile  ? Let  us  consult  analogy,  and  it  will  lead  us  to  an  affirmative 
solution  of  this  question.  We  everywhere  see  these  same  moral  impressions 
change  and  modify  the  secretions,  sometimes  increase  them,  and  sometimes 
diminish  them  or  suspend  them  altogether.  We  may  here  refer  to  the  influence 
of  different  species  of  emotions,  on  the  secretion  of  tears,  of  the  perspiration,  etc. 

4thly.  Some  persons,  in  the  enjoyment  of  good  health,  are  suddenly  seized  with 
an  acute,  lancinating  pain,  intolerably  severe,  continued,  or  returning  at  intervals, 
seated  in  the  right  hypochondrium  near  the  epigastrium.  After  this  pain,  they 
are  attacked  with  jaundice,  which  lasts  for  a longer  or  shorter  time,  then  disap- 
pears till  a new  pain  brings  on  a new  attack  of  jaundice.  I think  that,  in  some 
cases,  the  cause  of  this  pain,  and  of  the  subsequent  jaundice,  has  been  rightly 
referred  to  a calculous  concretion  in  the  biliary  passages.  But  is  that  the  only 
cause  of  it  ? In  some  persons  thejaundice  has  disappeared  with  the  pain,  with- 
out their  having  ever  passed  a stone.  To  be  sure  it  might  be  said  that  then  the 
concretion  produced  the  pain  and  jaundice  merely  by  its  presence  in  the  hepatic 
duct,  and  that  these  two  symptoms  ceased  in  consequence  of  the  passage  of  the 
calculus  into  the  cystic  duct,  and  thence  into  the  gall-bladder  ; but  then  it  should 
be  found  in  the  latter.  Now,  in  an  individual  whose  body  I opened,  who,  a little 
time  before  his  death,  had  complained  of  a very  acute  pain  in  the  region  of  the 
liver  with  this  jaundice,  and  in  whom  this  jaundice  continued  even  when  he 
died,  I found  no  trace  of  calculus  either  in  the  biliary  ducts,  or  in  the  gall- 
bladder ; this  person  also  laboured  under  aneurism  of  the  heart.  It  may  further 
be  observed,  that  very  often  very  large  calculi  are  found  in  the  biliary  passages, 
without  their  ever  having  occasioned  any  considerable  pain  ; and  that  many  per- 
sons have  passed  a great  number  of  them,  without  having  ever  experienced  any 
thing  like  those  acute,  violent  pains,  which  resemble  a neuralgia  with  respect  to 
their  mode  of  appearance,  their  returns,  their  nature,  and  their  intensity  : I 
would  accordingly  feel  inclined  to  think  that  one  of  the  varieties,  at  least,  of  the 
affection  designated  hepatic  colic , is  nothing  but  neuralgia  seated  in  the  hepatic 
plexus. 

One  of  its  most  remarkable  effects  should  be  to  modify,  or,  more  properly 
speaking,  to  suspend  the  secretion  of  bile,  so  as  to  produce  jaundice.  What  is 
there  surprising  in  this,  if  this  same  effect  is  produced  by  a mere  mental  emo- 
tion ? Is  it  not  in  a similar  manner  to  the  suspension  of  the  secretion  of  the  intes- 
tinal mucus,  that  the  painful  constipation  of  lead-colic  seems  to  be  owing,  which 
also  appears  to  be  a neuralgia,  seated  in  another  portion  of  the  plexuses  of  the 
great  sympathetic  ? Do  we  not  also  see  the  most  remarkable  modifications  in 
the  secretion  of  the  tears,  and  of  the  nasal  mucus,  accompany  different  neural- 
gias of  the  face  ? Again,  among  the  proofs  of  the  nervous  influence  over  the 


DISEASES  OF  THE  ABDOMEN. 


321 


secretions,  do  we  not  know  that  in  animals,  in  whom  the  nerves  of  the  fifth 
pair  no  longer  communicate  with  the  encephalon,  the  surface  of  the  eye  and 
nostrils  are  remarkably  dry  ? If  all  these  facts  prove  beyond  doubt,  that  under 
the  vitiated  influence  of  the  nervous  system,  most  of  the  secretions  are  sensibly 
modified,  it  must  be  granted  that  the  same  may  happen  with  respect  to  the  liver  ; 
and  if,  on  the  one  hand,  the  symptoms  observed  during  life  resemble  those  of 
the  neuralgic  affections,  of  which  other  organs  are  the  seat;  if  th  e post-mortem 
examination  discovers  nothing  which  can  account  for  those  symptoms,  it  must 
be  acknowledged  that  the  opinion  which  we  have  now  expressed,  and  which 
consists  in  regarding  certain  hepatic  colics  as  neuralgic,  is  at  least  extremely 
probable. 

5thly.  There  are  some  individuals  in  whom  jaundice  arises,  becomes  deve- 
loped, and  terminates  without  having  been  either  preceded  or  accompanied  by 
any  species  of  symptom  which  could  at  all  indicate  any  affection  of  the  liver,  or  of 
any  other  organ.  These  persons  would  not  consider  themselves  as  ill,  if  they 
did  not  know  that  they  were  yellow.  Most  commonly,  in  this  case,  the  bile 
continues  to  flow  into  the  duodenum,  as  is  indicated  by  the  nature  of  the  stools. 
When  this  takes  place,  the  appetite  is  retained,  no  disturbance  presents  itself  in 
the  digestive  functions,  so  that  then  there  is  very  little  probability  that  the  jaun- 
dice had  its  origin  in  irritation  of  the  digestive  passages,  and  particularly  of  the 
duodenum,  unless  it  be  admitted  that  there  may  be  duodenitis  without  any  species 
of  symptom  indicating  its  existence. 

Such  are  the  different  states  of  the  system  in  which  icterus  may  appear. 
Hitherto  we  have  not  yet  deviated  from  the  strict  observation  of  facts  ; but,  if 
we  wish  to  inquire  how,  in  consequence  of  one  of  these  morbid  states  existing 
in  the  liver  or  elsewhere,  it  happens  that  a yellow  colouring  matter  comes  to 
impregnate  most  of  the  tissues,  and  is  observed  also  in  the  liquids,  we  should 
find  many  difficulties  to  solve.  Many  physicians  think  that  every  jaundice  is 
produced  by  the  bile,  which,  being  absorbed  in  the  liver,  enters  into  the  torrent 
of  the  circulation,  and  is  carried  with  the  blood  into  all  the  tissues;  but  such 
absorption  stands  in  need  of  proof.  What  fact  demonstrates  it,  what  analogy 
even  warrants  us  in  supposing  it,  in  those  numerous  cases  where  jaundice  ac- 
companies different  organic  diseases  of  the  liver,  or  where  it  comes  on  after  a 
strong  mental  emotion  ? Do  we  see  that  the  nervous  influence,  under  other  cir- 
cumstances, increases  absorption  ? If  we  must  choose  an  hypothesis,  I would 
prefer  the  opinion  according  to  which  it  is  admitted  that  jaundice  supervenes, 
when  the  liver,  changed  in  its  texture  or  in  its  functions,  ceases  to  separate  from 
the  mass  of  blood  the  materials  of  the  bile  which  are  supposed  to  exist  therein. 
These  materials,  to  be  sure,  have  been  found  only  in  icteric  patients  ; but  urea 
also  has  only  been  found  in  the  blood  of  animals  whose  kidneys  had  been  re- 
moved. A fair  interpretation-  of  this  last  fact  has,  I think,  been  given,  by  saying 
that  the  quantity  of  urea  which  exists  in  the  blood  normally,  cannot  be  discovered 
in  it,  because  it  exists  in  it  in  too  small  a quantity,  being  eliminated  by  the  kid- 
neys according  as  it  is  formed.  The  same  may  be  said  of  the  absence  of  the 
materials  of  the  bile  in  the  blood,  when  there  is  no  jaundice.  The  absorption 
of  the  bile  would  seem  more  natural  to  admit,  in  cases  of  jaundice  where  there 
is  obliteration  of  the  biliary  ducts.  But  even  in  these  cases  the  jaundice  may 
be  accounted  for  in  another  way  : the  bile  then  ceases  to  be  separated  from  the 
blood,  because  this  separation  would  then  be  unattended  with  any  result.  No- 
thing can  now  pass  by  the  ductus  choledochus,  the  liquid  to  which  it  affords  a 
passage  will  be  no  longer  formed.  There  surely  is  nothing  more  surprising  in 
this  than  in  the  circumstance  that,  under  the  influence  of  an  irritation  which 
acts  only  on  the  intestinal  extremity  of  the  ductus  choledochus,  the  bile  flows 
more  abundantly  into  the  duodenum.  In  both  cases  there  is  equally  a corre- 
spondence of  organic  actions.  It  is  a particular  application  of  the  law  of  synergy, 
as  laid  down  by  Barthez. 


322 


ANDRAL’S  MEDICAL  CLINIC. 


It  is  possible,  also,  that  in  some  cases  the  yellow  tint  of  the  skin  does  not 
depend  on  the  presence  of  bile  in  the  blood,  but  rather  on  a sort  of  general  ec- 
chymosis,  which  takes  place  in  the  reticular  layer  of  the  cutis.  May  it  not  be 
so  in  several  cases  of  jaundice  of  new-born  infants,  and  in  the  yellow  fever  ? 


ARTICLE  II. 

general  symptoms,  or  disturbances  presented  by  the  functions 

OF  THE  DIFFERENT  SYSTEMS  IN  DISEASES  OF  THE  LIVER. 

17.  The  disturbance  which  these  functions  undergo  is  very  variable,  not  only 
according  to  the  different  affections  with  which  the  liver  may  be  attacked,  but 
also  in  one  and  the  same  affection,  according  to  its  acute  or  chronic  state,  its 
different  degrees  of  intensity,  and  more  particularly  according  to  the  habit  of  the 
individual  attacked.  Of  these  alterations  of  function  some  are  purely  mechanical, 
such  are  those  serous  collections  of  which  the  peritoneum  and  several  portions 
of  the  cellular  tissue  become  the  seat,  when  the  liver  does  not  afford  as  free  a 
passage  as  usual  to  the  blood  which  traverses  it.  Other  alterations  of  func- 
tions are  the  result  of  different  organic  lesions,  which  almost  always  accompany 
diseases  of  the  liver;  observation,  in  fact,  proves  that  in  these  diseases  there  is 
often  a complication  of  gastro-intestinal  inflammation,  which  also  is  sometimes 
primary  and  sometimes  secondary  to  the  affection  of  the  liver.  Other  altera- 
tions of  function  should  be  referred  probably  to  the  bad  qualities  of  the  bile  which 
comes  into  the  duodenum  ; thence  arise  certain  disturbances  of  digestion,  whilst 
others,  again,  are  merely  sympathetic. 

The  symptoms  resulting  from  these  different  alterations  of  function,  are  often 
more  marked  than  the  local  symptoms  spoken  of  in  the  preceding  article.  They 
may  present  themselves  either  after  the  latter,  or  before  them ; they  may  exist 
alone  during  the  entire  course  of  the  disease,  and  then  their  cause  is  frequently 
undiscovered,  until  a post-mortem  examination  has  taken  place.  They  are 
sometimes  observed  to  exist  only  in  an  intermittent  form  : in  the  intermission 
the  disease  of  the  liver  sometimes  remain  manifest,  being  reduced  to  some  local 
symptoms  ; the  latter  are  sometimes  either  very  obscure,  or  none  at  all.  If 
the  hepatic  affection  has  as  yet  made  but  little  progress,  the  patient’s  embon- 
point is  still  retained,  the  strength  is  intact ; and  in  the  interval  between  the 
febrile  disturbances,  for  instance,  which  are  observed  from  time  to  time,  and 
which  may  or  may  not  be  accompanied  with  tumefaction  and  pain  of  the  hepatic 
region,  the  individuals  enjoy  good  health,  and  there  is  no  reason  for  supposing 
that  any  organ  in  them  is  seriously  affected.  If,  on  the  contrary,  the  disease 
of  the  liver  is  more  advanced,  there  remains,  in  the  interval  between  these 
general  symptoms,  an  habitual  state  of  illness,  a state  of  wasting,  which  puts  it 
beyond  all  doubt  that  some  important  organ  is  seriously  involved. 

There  are,  again,  diseases  of  the  liver  which,  for  the  greatest  part  of  their 
duration,  do  not  in  any  way  disturb  the  different  functions.  This  principally 
happens  in  those  cases  where  hydatids,  even  of  considerable  size,  are  developed 
in  the  liver,  this  organ  not  having  undergone  any  other  alteration.  Very  often, 
under  such  circumstances,  the  digestion  is  not  deranged,  the  circulation  remains 
in  its  normal  state,  there  is  not  even  emaciation,  the  colour  of  the  skin  is  natu- 
ral, and,  as  there  is  not  most  ordinarily  in  this  case  any  pain,  it  follows  that,  in 
order  to  discover  the  disease  of  the  liver,  there  remains  most  commonly  no  other 
sign  but  the  tumour  formed  in  the  hypochondrium  by  the  hydatiferous  sac. 
But  this  tumour  may  even  not  exist ; so  that  in  more  than  one  case  of  this  kind 
it  was  only  after  death  that  there  was  anything  to  indicate  the  diseased  state  of 
the  liver  ; and  oftentimes  we  have  been  not  a little  surprised  to  find  immense 


DISEASES  OF  THE  ABDOMEN.  22 c 

pouches  full  of  hydatids  in  the  liver  of  persons  in  whom  nothing  during  life 
could  have  excited  any  suspicion  of  any  affection  of  this  organ. 


SECTION  I. 

DISTURBANCE  OF  DIGESTION. 

18.  The  function  of  digestion  is  more  frequently  disturbed  in  the  different 
diseases  of  the  liver  than  any  other  function ; from  this  disturbance  sy  mptoms 
arise  often  more  serious  and  more  alarming  than  those  occasioned  even  by  the 
disease  of  the  biliary  apparatus.  But  here  first  a question  arises,  namely,  whe- 
ther a great  many  diseases  of  the  liver  are  not  occasioned,  in  the  first  instance, 
by  a gastro-intestinal  affection.  The  observation  of  the  symptoms  inclines  us 
to  coincide  with  M.  Broussais’  opinion  on  this  point,  who  admits  that,  inmost 
of  the  cases  of  inflammation  of  the  liver,  there  was  duodenitis  in  the  first  in- 
stance. Sometimes,  also,  the  post-mortem  examination  discovered  no  other 
change  in  icteric  patients,  except  intense  inflammation  of  the  duodenum,  which 
seemed  to  have  extended  to  the  biliary  ducts.  The  examination  of  the  causes 
under  whose  influence  chronic  hepatitis  is  frequently  developed,  would  incline 
one  to  place  the  origin  of  it  in  the  digestive  tube.  The  result,  in  fact,  of  our 
observation  is,  that  the  great  majority  of  persons  who  died  of  chronic  hepa- 
titis, whose  history  has  been  collected  by  us,  had  indulged  freely  in  alcoholic 
liquors.*  One  can  readily  conceive  how  the  the  excitement,  habitually  pro- 
duced by  these  on  the  digestive  mucous  membrane,  by  continuity  of  tissue  to 
the  mucous  membrane  of  the  excretory  bile  ducts,  and  thence  to  the  hepatic 
parenchyma.  And  further  experience  has  proved  that  alcohol,  introduced  into 
the  digestive  passages  of  an  animal,  is  rapidly  absorbed.  Now,  may  not  the 
alcoholic  molecules,  carried  directly  into  the  liver  by  the  meseraic  veins,  directly 
produce  a powerful  irritation  in  this  organ  ? Again,  it  would  be  possible  that, 
under  some  circumstances,  the  irritation  extended  from  the  intestines  to  the 
liver  through  the  medium  of  venous  inflammation.  M.  Ribes  first  proposed 
this  opinion.  Careful  dissection  has  satisfied  this  skilful  anatomist  that  erysi- 
pelas is  often  accompanied  by  an  inflammation  of  the  veins ; and  from  this  he 
thinks  that  it  would  not  be  impossible,  that  in  certain  gastro-intestinal  inflamma- 
tions, the  veins  which  arise  on  the  surface  of  the  mucous  membrane  should  be 
attacked  with  inflammation ; that  this  extended  from  the  small  meseraic  veins 
to  the  trunk  of  the  vena  portae,  and  thus  reached  the  parenchyma  of  the  liver. 
We  have  met  two  cases  which  seem  to  confirm  this  opinion.  One  of  these 
was  that  of  an  individual  who  died  in  the  Charite.  He  had  presented  most  of 
the  symptoms  of  a bad  continued  fever ; at  first,  there  was  violent  reaction, 
skin  very  hot  and  dry,  pulse  full,  tongue  covered  with  a yellowish  coat  and 
dotted  with  red  points,  weight  in  the  epigastrium,  diarrhoea  ; then  painful  ten- 
sion towards  the  region  of  the  liver,  slight  yellow  tint  of  the  conjunctiva  and  of 
all  the  cutaneous  surface ; after  this  time  rapid  prostration,  tongue  dry,  teeth 
and  lips  dark-coloured,  evacuations  passed  involuntarily,  low  delirium  and  death. 

The  post-mortem  detected:  — 1st,  a little  dotted  injection  towards  the  great 
cul-de-sac  of  the  stomach,  which  was  in  the  mucous  membrane  ; the  membrane 
was  not  softened ; it  existed  in  several  patches,  which,  if  put  together,  might 
equal  about  a five-franc  piece  ; 2dly,  a healthy  state  of  the  duodenum,  jejunum, 
and  commencement  of  the  ileum  (white  appearance  of  the  mucous  membrane, 

slight  venous  injection  beneath  it) ; 3dly,  considerable  injection  of  the  mucous 

♦ 

* These  cases,  of  course,  refer  only  to  the  lower  classes  of  society. 


324 


ANDRAL’S  MEDICAL  CLINIC. 


membrane  of  the  ileum  in  its  lower  third,  as  also  of  the  caecum  ; 4thly,  intense 
redness  of  the  inner  surface  of  the  inferior  mesenteric  vein  of  the  trunk  of 
the  vena  portae,  and  of  all  its  hepatic  ramifications,  as  far  as  the  scalpel  could 
trace  them.  The  liver  itself  was  large,  very  red,  and  gorged  with  friable  blood. 
The  splenic  vein  was  not  red,  nor  was  the  vena  cava,  nor  its  divisions  ; but  the 
redness  reappeared  in  the  right  auricle  of  the  heart,  and  in  the  ventricle  of  the  same 
side  ; it  was  also  found,  but  in  a slight  degree,  in  the  trunk  of  the  pulmonary 
artery.  The  aorta,  on  the  contrary,  had  retained  its  natural  whiteness.  We 
carefully  noticed  this  inequality  of  colour  in  the  different  parts  of  the  vascular 
system,  because  we  think  it  proves  that  where  redness  did  exist,  it  could  not  be 
considered  as  a mere  effect  of  sanguineous  imbibition.  For  why  should  not 
the  latter  effect  have  been  produced  equally  in  every  part,  in  the  vena  cava  as 
in  the  vena  portae,  in  the  aorta  as  in  the  pulmonary  artery?  The  blood  con- 
tained in  these  several  vessels  presented  everywhere  the  same  physical  condi- 
tions. From  this  we  think  we  may  conclude  that  there  was  in  this  case  a real 
inflammation  of  the  abdominal  venous  system,  which  extended  to  the  liver, 
then  to  the  right  cavities  of  the  heart,  and  which  commenced  to  attack  the  pul- 
monary artery  when  death  took  place.  The  disease  had  presented  as  it  were 
two  periods  satisfactorily  explained  by  the  lesions  found  on  the  dead  body.  If 
we  compare  these  lesions  with  the  symptoms,  we  shall  be  inclined  to  admit, 
that  at  first  there  was  but  a slight  gastro-enterite  ; thence  the  symptoms  of  bilious 
fever  which  existed  at  the  commencement.  Subsequently  it  was  changed  into 
an  adynamic  fever.  Painful  tension  of  the  right  hypochondrium,  and  com- 
mencing jaundice,  was  all  that  was  then  observed.  Were  not  these  symptoms 
owing  to  phlebitis,  which  on  reaching  the  liver  produced  inflammation  of  it  ? 
It  was  so  much  the  less  probable  that  in  this  case  the  inflammation  extended 
from  the  intestine  to  the  liver  through  the  medium  of  the  mucous  membranes, 
as  the  duodenum  was  found  to  be  exempt  from  any  appreciable  change.  It  is 
not  necessary  to  say  that  this  case  militates  in  favour  of  the  opinion  of 
MM.  Bouillaud  and  Ribes,  who  make  vascular  inflammations  perform  a con- 
siderable part  in  the  production  of  what  are  called  essential  fevers. 

Another  patient  entered  the  Charite  labouring  under  ascites.  (We  have  given 
the  case  of  this  individual  in  another  part  of  the  work  ; a cancerous  tumour  was 
found  in  the  pericardium.)  At  the  post-mortem  examination  we  found  red  in- 
duration of  the  liver;  on  making  an  incision  into  the  veins  of  this  viseus  we 
were  struck  with  the  bright  redness  of  their  internal  surface.  On  approaching 
the  trunk  of  the  vena  portae  we  observed  that  the  internal  membrane  of  this 
vein,  and  of  its  principal  hepatic  branches,  might  be  detached  from  the  subja- 
cent tissues  much  more  easily  than  usual  ; it  was  also  much  softer  and  more 
friable  than  in  its  ordinary  state.  In  some  branches  a sort  of  pseudo-membrane 
lined  the  venous  parietes  in  the  form  of  a thin  transparent  and  apparently  inor- 
ganic web.  The  trunk  itself  of  the  vena  portae,  as  well  as  the  principal  branches 
which  converge  towards  the  liver  in  order  to  give  rise  to  it,  presented  on  their 
internal  surface  the  same  redness,  and  the  same  friability  of  their  membrane. 
In  the  peritoneum  there  was  a serous  collection  without  any  other  trace  of  in- 
flammation. In  the  digestive  tube  signs  of  chronic  inflammation  were  found, 
such  as  the  mammillated  appearance  and  brownish  colour  of  the  gastric  mucous 
membrane,  the  same  colour  in  the  duodenum,  some  ulcerations  and  remarkable 
development  of  the  follicles,  with  a black  colour  around  them  towards  the  termi- 
nation of  the  small  intestine,  in  the  caecum,  and  at  the  commencement  of  the 
colon.  It  may  be  observed,  that  through  the  rest  of  the  vascular  system  the  in- 
ternal surface  of  the  vessels  presented  a white  colour. 

Several  anatomical  characters  are  here  found  combined  to  prove  the  exist- 
ence of  inflammation  of  the  vena  portae  and  of  its  divisions,  whether  hepatic  or 
abdominal.  This  inflammation  coincided  with  double  chronic  inflammation  of 


DISEASES  OF  THE  ABDOMEN. 


325 


the  liver  and  digestive  tub#  ; and  here  again  it  is  possible,  though  it  is  not  de- 
monstrated, that  the  inflammation  attacked  successively,  1st,  the  intestine  ; 
2dly,  the  venous  system,  which  carries  the  blood  from  this  intestine  to  the  liver; 
3dly,  the  liver  itself.  What  warrants  us  still  further  in  making  this  suppo- 
sition is,  that  we  find  from  our  notes  that  the  disease  commenced  by  diarrhoea, 
which  seemed  to  be  the  only  affection  for  a year  at  least.  It  was  not  till  after 
this  that  some  slight  pains  began  to  be  felt  in  the  right  hypochondrium.  The 
patient  had  jaundice  twice,  and  at  a still  later  period  ascites  came  on.  This 
succession  of  symptoms  indicates  at  least  that  the  disease  of  the  liver  was  con- 
secutive to  that  of  the  intestine. 

19.  Whatever  be  the  way  in  which  irritation  extends  from  the  intestine  to 
the  liver,  it  may  present  itself  in  its  primary  and  consecutive  seat  with  numer- 
ous degrees,  and  in  very  different  forms.  First,  in  the  intestine  all  the  disturb- 
ance may  be  confined  to  mere  excitement,  whether  a simple  attack,  as  when 
after  a slight  excess  at  table,  jaundice  manifests  itself,  with  fever  and  painful 
tension  of  the  right  hypochondrium  ; or  whether  the  attack  be  repeated,  as  when 
alcoholic  liquors  are  frequently  introduced  into  the  digestive  passages.  In  these 
different  cases  the  excitement  in  the  intestine  does  not  seem  to  rise  to  the  de- 
gree of  inflammation,  which,  on  the  contrary,  manifests  itself  in  the  more  irrita- 
ble liver.  At  other  times  there  is  really  chronie  gastro-enteritis  ; whilst  at  other 
times  it  is  during  the  course  of  a well-marked  acute  gastro-enteritis  that  hepa- 
titis manifests  itself.  With  respect  to  the  forms'  which  the  latter  presents, 
when  it  succeeds  gastro-intestinal  irritation,  they  are  very  varied.  Sometimes 
it  is  chronic  from  its  onset,  gives  rise  to  no  well-marked  local  symptom,  and  it 
is  not  till  a long  time  after  it  has  commenced  that  some  signs  indicate  its  exist- 
ence. Sometimes  jaundice  is  the  only  symptom  observed,  which  appears  during 
the  progress  of  an  intestinal  inflammation  ; this  is  not  attended  either  by  heat 
or  tumefaction  of  the  hypochondrium.  In  this  case  the  post-mortem  examina- 
tion may  detect  three  states  of  the  liver  : 1st,  an  inflammatory  state  of  its  paren- 
chyma indicated  by  intense  redness,  considerable  sanguineous  engorgement,  and 
well-marked  softening;*  *2dly,  nothing  unusual,  at  least  in  appearance,  in  the 
hepatic  parenchyma,  but  perceptible  tumefaction  of  the  internal  membrane  of 
the  ductus  choledochus  and  ductus  hepaticus,  the  result  of  which  is  complete  or 
incomplete  obstruction  of  these  ducts  ; 3dly,  no  appreciable  lesion,  either  of  the 
liver  or  of  its  excretory  apparatus  ; which  is  no  proof  that  the  latter  has  been 
the  seat  of  lesion  during  life,  as  I shall  endeavour  to  demonstrate  presently. 
With  these  three  states  of  the  liver  the  intestine  is  found  in  different  degrees  of 
inflammation,  and  in  different  points  of  its  extent. 

In  other  individuals  hepatitis  consecutive  to  an  intestinal  inflammation  announces 
itself  from  its  onset  by  more  marked  symptoms  ; for  jaundice  alone  does  not 
prove  the  existence  of  hepatitis.  The  patients  feel  some  pain  in  different  points 
of  the  right  hypochondrium,  or  on  the  same  side  of  the  chest ; pain  is  felt  in 
this  same  hypochondrium,  &c.  These  different  symptoms  of  hepatitis  may 
present  themselves  but  once  during  the  course  of  chronic  gastro-enteritis  ; they 
may  then  either  disappear  or  continue,  either  with  or  without  intestinal  inflam- 
mation. In  other  patients  these  symptoms  appear  and  disappear  several  times  ; 
in  the  same  way,  for  instance,  as  in  the  course  of  chonic  stomatitis,  the  salivary 
glands  are  often  inflamed  only  at  intervals,  or  in  the  same  way  as  wherever  a 
chronic  inflammation  continues,  the  inflammatory  swelling  of  the  lymphatic  gan- 

* In  an  excellent  article  on  abscesses  of  the  liver,  M.  Louis  states  that  he  found  the  hepatic 
parenchyma  around  these  abscesses  red  and  softened,  which  further  proves  that  redness  and 
softening  of  the  liver  should  be  placed  among  the  lesions  which  inflammation  may  produce  in 
the  organ.  I feel  additional  confidence  in  my  opinions  when  I. find  them  coincide  with  those 
of  so  accurate  an  observer. 

28 


326 


ANDRAL’S  MEDICAL  CLINIC. 


glions  in  the  neighbourhood  appears  only  at  intervals.  But  in  these  a period 
generally  arrives  when  the  engorgement  becomes  permanent.  This  also  fre- 
quently happens  with  respect  to  the  liver.  When,  during  the  course  of  a chronic 
gastro-enteritis,  either  attacks  of  jaundice  have  been  seen  to  supervene  several 
times,  which  were  more  or  less  prolonged,  and  were  repeated  at  intervals  more 
or  less  remote,  or  transient  pains  towards  the  region  of  the  liver,  or  tumefaction 
of  this  organ  equally  transient,  a period  may  also  come  when  one  or  more  of 
these  symptoms  become  permanent ; then  it  must  be  admitted,  either  that  before 
this  last  period  the  affection  of  the  liver,  though  not  ceasing,  was  still  so 
light  as  to  indicate  its  existence  only  by  intermittent  symptoms,  which  super- 
vened every  time  the  affection  became  aggravated ; or  else,  a thing  which  is 
more  probable,  that  this  affection  was  itself  intermittent,  subjected  probably  in 
its  return  to  the  state  of  the  digestive  tube. 

20.  Hitherto  we  have  been  considering  only  the  case  where  the  hepatitis  seems 
to  be  consecutive  to  a gastro-intestinal  inflammation.  Another  case  more  uncom- 
mon, but  one  which  appears  no  less  real,  is  that  wherein  the  latter  is,  on  the  con- 
trary, consecutive.  More  than  once  have  we  observed  patients  in  whom  no 
symptom  had  ever  announced  any  disturbance  whatever  of  the  digestive  functions ; 
in  them,  however,  there  was  unquestionably  an  affection  of  the  biliary  system, 
such  as  hypertrophy  of  the  liver,  red  or  white  induration  of  that  viscus,  its  can- 
cerous degeneration,  etc.  During  the  course  of  one  of  these  affections,  and  a 
long  time  after  its  commencement,  the  function  of  digestion. only  began  to  be 
disturbed.  This  case  is  one  of  the  most  favourable  that  can  be  met  in  cases  of 
diseases  of  the  liver ; the  patients  under  such  circumstances  decline,  but  very 
•slowly,  for  the  function  of  nutrition  may  still  continue. 

When  a gastro-intestinal  inflammation  supervenes  as  a complication  of  an 
affection  of  the  liver,  it  may  be  set  up  in  a continued  form,  or  bo  only  transient, 
or  return  at  intervals  more  or  less  distant.  In  the  two  latter  cases  its  form  is 
acute  ; in  the  former  it  may  be  either  acute  or  chronic  ; if  it  is  acute,  nothing  is 
more  variable  than  the  symptoms  to  which  it  gives  rise  ; and  from  these  different 
groups  of  symptoms  there  arise  diseases  of  different  aspects,  to  which  parti- 
cular names  have  been  assigned.  At  first  this  gastro-enterite  may  indicate  its 
existence  principally  by  local  symptoms.  Thus,  the  tongue,  which  had  retained 
its  natural  state  as  long  as  there  was  only  an  affection  of  the  liver,  is  covered 
with  different  coats,  becomes  red,  dry,  cleft,  etc.  The  whitish  coat  which 
covers  it  is  dotted  with  bright  red  points.  The  thirst,  which  till  then  was 
absent,  becomes  intense  ; there  is  vomiting,  pain  in  the  epigastrium,  and  diar- 
rhoea. We  have  sometimes  seen,  in  such  cases,  diseases  of  the  liver,  which 
had  proceeded  slowly,  which  had  as  yet  produced  no  serious  alteration  in  the 
constitution,  and  which  till  then  had  not  been  accompanied  by  any  disturbance 
in  the  function  of  digestion.,  become  complicated  with  all  the  symptoms  of 
cholera  morbus,  such  as  violent  vomiting,  very  copious  alvine  evacuations,  sud- 
den cold  of  the  cutaneous  surface : in  two  or  three  days  the  patients  died ; and 
on  opening  the  bodies  we  found  a bright  red  injection  of  the  greater  part  of  the 
gastro-intestinal  mucous  membrane,  without  any  other  alteration  ; so  that  this 
inflammation  was  more  remarkable  for  its  extent  than  for  its  severity  in  each  of 
the  points  which  it  occupied. 

At  other  times,  persons  labouring  for  a long  time  under  diseases  of  the  liver, 
but  still  far  from  being  exhausted,  ard  seized  suddenly  with  continued  fever; 
their  tongue  becomes  red,  dry,  and  then  black  ; their  abdomen  becomes  tympa- 
nitic, diarrhoea  supervenes  ; they  fall  into  a complete  adynamic  state,  and  die 
rapidly.  On  opening  the  body,  traces  of  acute  inflammation  are  found  in  the 
digestive  tube  ; this  sometimes  appears  to  have  been  intense  ; the  mucous  mem- 
brane is  very  red,  softened,  ulcerated  in  several  points,  and  the  severity  of  the 
symptoms  is  directly  proportioned  to  that  of  the  lesions ; sometimes,  on  the 


DISEASES  OF  THE  ABDOMEN. 


327 


contrary,  the  gastro-intestinal  inflammation  appears  very  slight;  in  the  mucous 
membrane  or  beneath  it,  there  is  observed  merely  some  vascular  injection,  more 
or  less  extensive  ; but  consider  that  this  inflammation  supervenes  in  an  indi- 
vidual already  exhausted  by  a chronic  affection  of  an  important  organ  ; and 
from  thence  there  exist  in  him  conditions  favourable  to  the  development  of  a 
state  of  very  great  prostration,  should  any  inflammation  intervene,  no  matter 
how  slight  such  inflammation  may  appear. 

Whatever  be  the  form  under  which  attacks  of  acute  gastro-enteritis  may  pre- 
sent themselves  during  the  progress  of  chronic  affections  of  the  liver,  it  is  import- 
ant to  know  that  they  are  one  of  the  frequent  causes  of  premature  death  in  a 
great  number  of  persons  labouring  under  these  affections.  It  may  so  happen 
that  the  disturbance  of  the  digestive  functions,  after  having  existed  at  the  onset 
at  a period  when  the  affection  of  the  liver  was  as  yet  but  little  marked,  disappears 
at  a later  period.  According  as  the  latter  affection  becomes  more  marked,  the 
digestive  function  is  found  to  return  to  its  normal  state,  and  does  not  become 
again  deranged  till  a very  advanced  period  of  the  disease  of  the  liver. 


SECTION  II. 

DISTURBANCE  OF  THE  CIRCULATION. 

21.  The  circulation  may  be  disturbed  in  diseases  of  the  liver,  either  sympa- 
thetically, as  in  the  case  of  the  heart  and  arteries,  or  in  a manner  purely 
mechanical,  as  takes  place  in  several  parts  of  the  venous  system,  in  the  case 
where  the  blood  contained  in  the  vena  portae  can  no  longer  freely  pass  through 
the  hepatic  parenchyma. 

A. SYMPATHETIC  DISTURBANCES  OF  THE  CIRCULATION. 

22.  First,  there  are  cases  of  affections  of  the  liver  where  the  circulation  is 
not  at  all  modified  in  any  way.  The  strength,  frequency,  and  rhythm  of  the 
pulse  are  natural,  the  temperature  of  the  skin  is  not  raised.  This  complete 
absence  of  fever  is  scarcely  ever  observed  in  acute  hepatitis  ; but  it  is  not  at  all 
uncommon  in  the  numerous  shades  of  chronic  hepatitis,  even  in  the  case  where 
purulent  abscesses  exist  in  the  substance  of  the  organ,  and  where  cancerous 
masses  have  attacked  a portion  of  it ; this  complete  apyrexia  is  still  much  more 
common  when  there  is  but  simple  hypertrophy  of  the  liver,  whether  of  its  entire 
structure,  or  of  either  of  its  substances,  or  when  it  has  undergone  greater  or  less 
atrophy. 

In  other  cases  the  circulation  presents  a marked  disturbance,  though  there 
may  be  as  yet  no  fever,  properly  so  called.  This  disturbance  consists  merely 
in  acceleration  of  the  pulse,  without  any  change  in  the  heat  of  the  skin.  Thus, 
unusual  frequency  of  the  pulse,  without  any  other  sign  of  fever,  often  accom- 
panies the  different  chronic  affections  of  the  liver  already  mentioned. 

Lastly,  there  may  be  fever,  properly  so  called  — that  is  to  say,  frequency  of 
the  pulse  — with  increase  in  the  temperature  of  the  skin  and  general  indisposi- 
tion. This  fever  may  accompany  the  disease  of  the  liver  during  its  entire  pro- 
gress, a thing  which  is  most  frequently  observed  in  cases  of  acute  hepatitis. 
What  is  then  remarkable  is  that  sometimes,  in  such  cases,  the  local  symptoms 
which  should  indicate  the  existence  of  the  hepatic  affection  are  very  obscure, 
nothing  is  observed  but  a continued  fever,  the  non-essentiality  of  which  can  be 
proved  only  by  a post-mortem  examination.  We  once  saw  such  a fever  pro- 
duced by  an  abscess  formed  in  the  liver.  This  was  in  the  case  of  a young  man 
who  habitually  enjoyed  good  health  ; after  a long  journey  on  horseback,  he  felt 
considerable  indisposition,  some  headach,  and  great  depression.  For  the  first 


323 


ANDIiAL’S  MEDICAL  CLINIC. 


three  days  he  considered  this  as  the  result  of  fatigue,  and  kept  quiet hut  on 
the  fourth  day  a shivering  fit  supervened,  and  feeling  himself  worse  he  entered 
the  hospital.  Two  days  after  his  admission,  that  is,  about  the  sixth  day  of  his 
illness,  we  saw  him  for  the  first  time.  He  was  then  in  a state  of  great  prostra- 
tion. The  redness  on  the  cheek  bones  contrasted  strikingly  with  the  yellow 
tint  over  the  remainder  of  the  face.  The  patient  complained  of  an  insupportable 
pain  of  the  head,  situate  over  the  orbits.  The  mouth  was  clammy,  without 
being  bitter  ; the  tongue  presented  a whitish,  uniform  appearance,  without  any 
red  points  ; the  appetite  was  lost,  but  there  was  neither  thirst,  nausea,  nor 
vomiting,  nor  any  pain  either  in  the  epigastrium  or  in  any  other  part  of  the  abdo- 
men, every  part  of  which  retained  its  natural  soft  feel.  There  was  some  con- 
stipation. Pulse  from  112  to  115;  it  was  strong  and  regular;  the  skin  was 
burning  hot  and  dr}'.  We  tried  to  no  purpose  to  ascertain  what  organ  was 
affected  in  this  case.  (Bleeding  and  diluent  drinks.)  From  the  seventh  to  the 
eleventh  day  he  continued  in  the  same  state  ; he  was  then  bled  from  the  foot 
with  the  view  of  relieving  the  headach.  On  the  night  of  the,  eleventh  day  his 
intellects  became  disturbed  for  the  first  time,  and  on  the  next  morning  we  found 
him  completely  delirious.  (Leeches  behind  the  ears,  sinapisms  to  the  lower 
extremities.)  From  the  twelfth  to  the  sixteenth  day  the  delirium  continued  ; it 
became  necessary  to  tie  him  in  order  to  prevent  him  from  escaping  from  the 
bed.  There  was  frequent  subsultus,  the  eyes  were  alternately  open  and  shut, 
fixed  or  rolling  rapidly  in  their  orbits  ; the  pupils  were  dilated  and  contracted 
alternately.  With  respect  to  the  digestive  passages  and  the  abdominal  organs 
in  general,  there  existed  no  new  symptom.  On  the  morning  of  the  seventeenth 
day,  the  patient  was  still  quite  vigorous,  as  appeared  from  the  energy  of  his 
movements,  and  the  strength  of  his  voice.  Towards  noon  he  died  unexpect- 
edly without  any  new  symptom  occurring.  Since  the  last  three  days  cam- 
phorated lavements  had  been  given,  and  blisters  had  been  applied  to  the  lower 
extremities. 

It  was  very  evident  that  this  person  died  of  an  affection  of  the  brain  ; but  he 
did  not  labour  under  it  at  the  lime  he  came  into  the  hospital  ; up  to  the  twelfth 
day  of  his  illness  he  had  presented  no  trace  of  it;  however  we  must  not  lose 
sight  of  the  intense  pain  of  head  which  he  complained  of  since  the  time  we  saw 
him,  and  which  was  so  severe  as  to  demand  special  treatment.  The  encepha- 
lon and  its  connexions  were  most  carefully  examined.  The  membranes  of  the 
brain  retained  their  natural  transparency  and  thickness  ; a few  spoonsful  of  clear 
serum  had  been  effused  into  the  ventricles  and  at  the  base  of  the  cranium.  The 
substance  of  the  encephalon  presented  nothing  unusual  with  respect  to  its  injec- 
tion, colour,  or  consistence.  The  spinal  cord  was  also  examined  ; it,  like  the 
brain,  was  free  from  any  appreciable  alteration.  The  thoracic  organs  were 
healthy.  The  stomach  presented  here  and  there  some  small  red  points,  which, 
all  put  together,  would  not  exceed  the  breadth  of  a franc  piece.  Over  the  re- 
mainder of  the  digestive  tube  nothing  was  found  but  a little  submucous  injection 
residing  in  the  large  veins.  Hitherto  no  lesion  of  any  organ  was  found  to  ac- 
count for  the  serious  symptoms  observed  during  life,  when  my  friend  Dr.  De- 
scieux  made  an  incision  in  the  liver,  which  on  the  outside  seemed  to  be  perfectly 
healthy.  What  was  our  astonishment,  when  at  the  bottom  of  this  incision  we 
found  an  abscess  large  enough  to  contain  an  orange  ! The  pus  was  of  a yel- 
lowish white  colour,  creamy  and  inodorous  ; it  was  in  immediate  contact  with 
the  substance  of  the  liver,  which  to  the  extent  of  several  inches  around  it  was 
redder  than  elsewhere,  and  remarkably  friable  ; slight  pressure  reduced  it  to  a 
reddish  pulp  ; this  abscess  was  situated  in  the  substance  of  the  right  lobe,  not 
far  from  the  convex  portion  of  this  lobe,  which  touches  the  diaphragm  near  the 
ribs.  No  other  organic  change. 

Here  then  is  an  abscess  of  the  liver  which  was  formed  without  producing 


DISEASES  OF  THE  ABDOMEN. 


329 


either  pain,  or  tumefaction  of  the  organ  or  jaundice  ; the  only  phenomenon  oc- 
casioned by  it  was  a continued  fever  ; the  cause  of  it  could  not  be  discovered 
during  life.  We  are  very  much  inclined  to  think  that  an  inflammatory  process 
commenced  in  the  liver,  on  the  very  day  when,  after  the  journey  on  horseback, 
signs  of  mere  fatigue  presented  themselves.  The  intense  headach  of  which  the 
patient  complained,  was  the  first  sympathetic  phenomenon  which  the  disease 
of  the  liver  occasioned  towards  the  brain.  At  a later  period  the  function  of  this 
organ  became  more  seriously  deranged,  and  it  was  from  the  sympathetic  irri- 
tation of  the  brain  that  the  patient  died.  The  original  cause,  however,  of  all 
the  phenomena  resided  in  the  liver. 

This  case  seems  to  furnish  a very  interesting  fact  in  favour  of  the  localisation 
of  fevers,  which,  during  life,  seem  not  to  be  referable  to  any  lesion  of  organs. 
Moreover  it  proves,  contrary  to  M.  Broussais’  opinion,  as  has  been  already 
observed  by  MM.  Boisseau,  Bouillaud,  Ribes,  etc..,  namely,  that  the  seat  of 
what  are  called  essential  fevers  is  not  necessarily  in  the  digestive  canal. 

23.  In  some  cases  of  chronic  affections  of  the  liver,  there  is  ordinarily  no 
fever,  but  at  periods  more  or  less  remote,  and  which  are  not  uniform  in  their 
return,  a febrile  disturbance  supervenes,  w'hich  may  last  for  some  hours  only, 
or  continue  for  several  days.  This  accidental  fever  depends  most  frequently  on 
a temporary  exasperation  of  the  lesion  of  the  liver,  which  from  being  chronic 
tends  to  pass  into  the  acute  form.  In  this  case,  at  the  same  time  that  fever 
manifests  itself,  we  often  see  the  local  symptoms  of  the  hepatic  affections  be- 
come much  more  marked.  Pain,  for  instance,  may  appear,  if  it  were  previously 
absent,  or  become  more  acute,  if  it  already  existed.  We  know  a lady,  who 
for  several  years  back  has  been  labouring  under  an  organic  affection  of  the  liver, 
which  organ  forms  a tumour  not  easily  circumscribed  in  the  right  hypochon- 
drium.  She  experiences  no  pain  in  it  except  occasionally;  this  pain  becomes 
much  more  acute,  generally  under  the  influence  of  appreciable  moral  causes, 
and  at  the  same  time  a very  violent  fever  is  observed  to  set  in,  accompanied 
often  by  delirium.  An  application  of  leeches  over  the  right  hypoehondrium 
usually  assuages  these  symptoms.  Here  the  exasperation  of  the  hepatic 
pain,  and  the  success  of  the  treatment  adopted,  do  not  allow  us  to  doubt  that 
the  cause  of  the  febrile  commotion,  and  of  the  cerebral  symptoms  which  accom- 
pany it,  must  reside  in  the  liver,  the  chronic  affection  of  which  organ  assumes 
for  a time  an  acute  character.  In  other  persons  the  irregular  returns  of  these 
accessions  of  fever  appear  to  be  less  connected  with  the  disease  of  the  liver,  than 
with  an  intercurring  inflammation  of  the  digestive  tube. 

24.  Observation  has  proved  that  certain  intermittent  fevers  are  connected 
with  an  organic  affection  of  the  liver.  But  here,  two  cases  may  present  them- 
selves; sometimes  the  intermittent  fever  precedes  this  affection,  or  at  least  the 
symptoms  which  indicate  it ; sometimes  it  becomes  developed  during  its  pro- 
gress.* 

B. DISTURBANCE  OF  THE  CIRCULATION,  OCCASIONED  BY  AN  OBSTACLE 

TO  THE  FREE  PASSAGE  OF  THE  BLOOD  WITHIN  THE  LIVER. 

25.  In  our  work  on  Pathological  Anatomy  we  have  detailed  the  results  of 

* Our  author  cites  here  two  cases,  in  one  of  which  hepatic  disease  was  observed  to  come  on 
during  the  course  of  an  intermittent  fever ; in  the  second,  the  intermittent  supervened  during 
the  progress  of  an  old  disease  of  the  liver,  the  progress  of  which  it  seemed  to  accelerate  in  a 
very  remarkable  manner.  M.  Portal,  our  author  remarks,  was  one  of  those  who  laid  particular 
stress  on  intermittent  fevers  which  are  occasioned  by  an  affection  of  the  liver,  or  which  at  least 
coincide  with  it.  It  has  been  well  observed,  that  such  fevers  never  yield  to  quinquina,  the 
effect  of  which  is  to  render  them  more  intractable,  by  contributing  to  aggravate  the  disease  of 
the  liver. — Tuans. 

28* 


330 


AND  HAL’S  MEDICAL  CLINIC. 


modern  experience  and  observation,  with  respect  to  partial  or  general  dropsies 
produced  by  an  obstacle  to  the  passage  of  the  blood.  There  is  also  a certain 
number  of  diseases  of  the  liver  which  are  accompanied  by  ascites,  and  in  which 
the  latter  affection  seems  owing  to  the  difficulty  which  the  venous  blood  expe- 
riences in  passing  through  the  hepatic  parenchyma.  These  diseases  are  not 
those,  as  might  be  supposed  a priori,  in  which  accidental  productions,  cancer- 
ous or  tuberculous  masses,  hydatids,  or  large  abscesses,  occupy  the  place  of 
the  tissue  of  the  liver.  In  these  different  cases,  dropsy  is  not  uniformly  ob- 
served, and  it  scarcely  comes  on  before  the  close  of  the  disease.  It  is  also 
rather  uncommon,  where  there  is  merely  hypertrophy  of  liver  without  increase 
in  its  consistence.  It  is  more  common  in  cases  of  red,  white,  grey,  or  green 
induration  of  the  hepatic  parenchyma.  Again,  it  is  principally  observed  in  a 
manner  almost  uniform  in  those  cases  wherein  the  size  of  the  liver  is  diminished, 
whether  this  diminution  affects  equally  the  two  substances,  or  whether  the 
white  substance  be  hypertrophied  at  the  same  time  the  red  is  atrophied,  or 
whether  this  latter  substance,  without  having  diminished  in  size,  has  become 
less  vascular  than  usual. 

Here  is  what  observation  teaches  us,  and  what  might  have  been  readily  anti- 
cipated, as  a consequence  of  the  researches  which  we  have  already  detailed 
respecting  the  morbid  anatomy  of  the  liver.  It  is  precisely  in  those  cases, 
wherein  one  may  best  admit  an  obliteration,  an  atrophy,  a cellular  or  fibrous 
transformation  of  some  of  the  vessels  which  ramify  through  the  liver,  that  we 
see  ascites  most  frequently  developed.  Nothing  is  more  easily  accounted  for 
than  its  production  under  such  circumstances.  Serum  accumulates  in  the  peri- 
toneum when  the  vena  portae  hepatica  ceases  to  give  a free  passage  to  the  abdo- 
minal venous  blood;  in  the  same  manner  as  a limb  becomes  infiltrated  when  its 
principal  vein  is  obstructed.  This  connexion. between  certain  partial  dropsies, 
and  an  obstacle  in  the  venous  circulation,  has  been  so  well  proved  by  my  learned 
friend,  M.  Bouillaud,  and  also  by  those  persons,  who,  after  him,  have  devoted 
themselves  to  researches  of  this  kind,  that  the  mere  existence  of  ascites,  which 
almost  invariably  accompanies  certain  diseases  of  the  liver,  might  again  bo 
given  as  a proof  that,  in  these  diseases,  there  is  an  obstacle  to  the  venous  cir- 
culation in  the  liver. 

That  kind  of  affection  of  the  liver,  in  which  ascites  most  usually  comes  on,  is 
one  of  those  whose  diagnosis  is  most  obscure.  In  this  case  one  cannotdiscover 
any  tumour,  as  the  size  of  the  liver  is  diminished  instead  of  being  increased  , 
very  seldom  there  is  any  pain,  and  seldom  are  there  observed  any  traces  of 
jaundice.  There  is  really  nothing  but  the  ascites  which  can  then  incline  one  to 
suspect  that  there  is  disease  of  the  liver.  Often  in  the  Charite  have  we  detected 
not  only  the  existence  of  this  disease,  but  we  have  been  able  to  determine  even 
its  nature  ; for  this  purpose  we  must  principally  look  to  the  way  in  which  the 
dropsy  commenced,  to  its  progress,  and  to  the  local  or  general  symptoms  which 
preceded  it.  First  we  may  distinguish  it  with  tolerable  certainty  from  a 
dropsy  produced  by  an  organic  affection  of  the  heart,  by  this  circumstance,  that 
in  this  last  case  the  first  traces  of  serous  effusion  very  seldom  manifest  them- 
selves in  the  abdomen,  they  appear  first  around  the  ankles,  then  in  the  legs  and 
thighs,  and  lastly  in  the  peritoneum.  Where,  on  the  contrary,  the  dropsy  is 
connected  with  an  affection  of  the  liver,  it  is  in  the  peritoneum  that  the  serum 
begins  to  accumulate,  and  it  is  only  secondarily  that  the  lower  extremities  be- 
came cedematous.  Anatomy  and  physiology  readily  account  for  these  differ- 
ences. Ascites  again  may  be  the  result  of  peritonitis,  but  most  frequently  there 
has*been  a period  of  the  disease  when  peritoneal  pains  were  felt.  Lastly,  ascites 
might  be  essential,  that  is,  without  any  cause  that  we  can  discover ; but  this  is 
extremely  rare,  and  the  greater  number  of  cases  of  ascites,  considered  as  essen- 
tial by  ancient  authors,  appear  to  have  been  precisely,  in  the  great  majority  of 


DISEASES  OF  THE  ABDOMEN. 


331 


circumstances,  either  the  result  of  a peritonitis  which  has  left  no  other  trace 
behind  it  but  a collection  of  serum,  or  the  product  of  those  diseases  of  the  liver 
now  under  consideration,  in  which  the  organ  has  become  atrophied,  whether 
it  be  at  the  same  time  studded  or  not  with  those  yellow  or  red  granulations 
whose  formation  we  have  already  explained. 

There  are  some  cases  where  the  ascites  results  also  from  an  obstacle  to  the 
free  circulation  of  the  blood  in  the  vena  portae,  but  this  obstacle  no  longer  resides 
in  the  liver  which  is  healthy  ; it  exists  along  the  course  of  the  trunk  of  the  vena 
portae,  or  of  its  principal  abdominal  divisions,  which  are  compressed  by  tumours 
of  different  kinds  and  different  sizes.  A fact  of  this  kind  was  presented  by  the 
following  case,  which  is  also  interesting  in  several  other  respects. 

A young  man,  twenty-four  years  of  age,  who  for  several  years  back  had  an 
indolent  engorgement  of  the  lymphatic  glands  on  both  sides  of  the  neck,  pre- 
sented several  of  the  rational,  signs  of  an  organic  affection  of  the  heart,  when  he 
entered  the  Charite.  Face  puffed,  livid  ;:  lips  and  alee  nasi  of  a purple  colour  ; 
oedema  of  the  eyelids  ; ascites,  but  very  slight  infiltration  of  the  lower  extre- 
mities. The  respiration  was  short  and  hurried  ; it  was  principally  performed 
by  the  action  of  the  ribs  ; he  could  not  lie  on  his  back  under  pain  of  suffocation, 
and  he  passed  his  nights  and  days  half-sitting  up  in  his  bed,  his  head  and  trunk 
being  supported  by  pillows.  This  difficulty  of  breathing  had  gradually  in- 
creased, but  it  was  chiefly  since  the  last  year  that  the  dyspnoea  became  painful 
to  the  patient ; it  was  constantly  increased  under  the  influence  of  moist  and 
rainy  weather.  The  chest,  when  percussed,  sounded  well  in  every  part; 
auscultation  detected  nothing  unusual  in  the  region  of  the  heart,  nor  in  any 
other  part,  so  as  to  incline  us  to  suspect  the  existence  of  a disease  of  this  organ 
or  of  the  large  vessels.  A mucous  rale  was  heard  in  different  parts  of  the 
chest ; in  other  parts  there  was  a dry,  sibilous  rale  ; in  other  parts  again  the 
respiratory  murmur  was  clear  but  loud.  For  several  months  back  the  patient 
had  been  labouring  under  a cold  he  had  never  spit  blood,  and  when  we  saw 
him,  he  had  merely  a slight  mucous  expectoration.  The  appetite  was  rather 
good,  and  he  had  habitually  a little  diarrhoea,  without  any  abdominal  pain.  The 
pulse  was  natural  with  respect  to  its  frequency,  strength,  and  rhythm. 

There  was  nothing  to  show  that  this  individual  had  an  organic  lesion  of  the 
heart,  and  yet  this  lesion  seemed  to  be  indicated  by  several  of  the  symptoms, 
such  as  the  appearance  of  the  countenance,  the  dropsy,  and  orthopnoea.  This 
dropsy  presented,  however,  one  circumstance  which  is  not  usually  met  in  dis- 
eases of  the  heart;  the  inferior  extremities  were  infiltrated  only  consecutively 
to  the  ascites,  and  again  this  infiltration  was  very  slight.  We  know,  on  the 
contrary,  that  dropsy  depending  on  disease  of  the  heart,  begins  in  the  great 
majority  of  cases  by  oedema  round  the  ankles. 

Auscultation  did  not  discover  the  cause  of  the  dyspnoea  either  in  the  heart  or 
in  the  lungs.  The  following  was  the  treatment  employed  ;.  bleeding,  local  and 
general ; blisters  to  the  chest  and  lower  extremities  diuretic  mixtures  ; frictions 
with  tincture  of  digitalis  and  squill  wine. 

For  the  six  weeks  following,  the  state  of  the  patient  underwent  no  perceptible 
change;  there  was  constant  orthopnoea;  the  respiration  became  short  the  moment 
the  patient  tried  to  leave  his  bed  for  a little.  We  never  observed  any  fever, 
properly  speaking.  Nothing  as  yet  announced  the  approaching  dissolution  of 
the  patient,  when,  without  any  appreciable  change  in  his  state,  he  was  seized 
on  a sudden  with  extreme  dyspnoea;  the  tracheal  rale  soon  supervened,  the 
respiration  became  embarrassed  as  in  apoplectic  patients,  and  in  a few  hours 
he  died. 

Post-mortem.  Nothing  remarkable  observed  in  the  thoracic  viscera,  except  a 
small  number  of  miliary  tubercles  scattered  through  the  pulmonary  parenchyma,, 
which  was  generally  engorged  but  healthy  and  full  of  air.  Some  old  cellular 


332 


ANDRAL’S  MEDICAL  CLINIC. 


adhesions  united  the  pleurae  costalis  and  pulmonalis  on  both  sides.  The  anterior 
mediastinum  was  occupied  by  a large  mass  of  tuberculated  lymphatic  ganglions. 
Through  this  mass  the  two  diaphragmatic  nerves  passed  ; it  was  impossible 
to  trace  them  through  the  numerous  ganglions  which  surrounded  and  pressed 
them  on  all  sides.  They  reappeared  at  a little  distance  from  the  diaphragm,  and 
from  the  point  where  they  became  disengaged  from  the  ganglionic  mass  to  their 
distribution  in  the  diaphragm,  these  nerves  were  remarkable  for  their  greyish 
colour,  resembling  that  which  the  optic  nerve  often  presents  when  it  goes  to  an 
eye  which  has  been  for  a long  time  in  a state  of  atrophy.  In  the  abdomen  the 
stomach  was  found  healthy;  numerous  tubercles  scattered  over  the  mucous 
membrane  of  the  small  intestine  ; some  ulcerations,  small  and  superficial,  to  the 
extent  of  some  inches  above  the  ileo-caecal  valve  ; a tubercle  about  the  size  of 
a filbert  in  the  cortical  substance  of  one  of  the  kidneys  ; cellular  adhesion  between 
the  diaphragm  and  liver,  the  tissue  of  which  was  healthy  ; the  spleen  was  soft 
and  of  considerable  size  ; a considerable  effusion  of  serum  into  the  peritoneum  ; 
and  lastly,  before  the  vertebral  column  an  enormous  mass  of  lymphatic  ganglions 
which  had  degenerated  into  tubercles,  which  forcibly  compressed  the  vena  cava 
on  the  one  hand,  and  the  vena  portae  on  the  other,  of  which  they  surrounded  the 
principal  abdominal  branches  as  well  as  the  trunk.  On  each  side  of  the  neck, 
from  the  edge  of  the  jaw  to  the  clavicles,  there  was  a large  string  of  tuber- 
culated lymphatic  glands,  like  those  of  the  thorax  and  abdomen.  Several  were 
placed  between  the  vessels  and  the  nerves  of  the  neck,  and  the  carotid  artery 
and  jugular  vein  were  found  separated  by  these  glands.  With  respect  to  the 
pneumogastric  nerve,  some  inches  below  the  origin  of  the  superior  laryngeal 
nerve,  it  became  lost  in  the  mass  of  ganglions,  in  the  midst  of  which  it  was 
impossible  to  find  it.  It  reappeared  a little  above  the  clavicle,  and  was  remark- 
able on  both  sides  for  its  flattened  appearance.  Each  axilla  was  occupied  by  a 
tumour  as  large  as  an  orange,  which  was  formed  of  a number  of  tuberculated 
lymphatic  glands.  The  thoracic  duct  contained  a small  quantity  of  reddish 
serum. 

26.  Independently  of  the  cause  of  dropsy,  which  appeared  to  be  the  com- 
pression of  the  large  venous  trunks,  this  case  appeared  to  possess  still  further 
interest,  in  consequence  of  the  state  in  which  several  of  the  nerves  were  found, 
which  contribute  to  the  function  of  respiration,  the  diaphragmatic  nerves  on  the 
one  hand,  and  the  two  cords  of  the  eighth  pair  on  the  other.  M.  Berard  has 
mentioned  the  case  of  an  individual  in  whom  no  other  lesion  was  found  to  ac- 
count for  the  very  great  dyspnoea  which  he  presented  during  life  except  a tumour 
developed  in  the  substance  of  one  of  the  diaphragmatic  nerves.  Here  not  only 
had  the  two  diaphragmatic  nerves  undergone  considerable  alteration,  which  was 
sufficiently  characterised  by  the  grey  colour  and  real  atrophy  of  their  lower  ex- 
tremity, but  moreover  the  two  pneumogastric  nerves  were  seriously  involved, 
as  was  manifestly  proved  by  the  flattened  form  they  presented  on  escaping  from 
the  lymphatic  tumour,  in  the  midst  of  which  it  was  impossible  to  trace  them. 
Now,  if  the  experiments  of  physiologists  have  proved  that  after  the  division  of 
the  eighth  pair  hematosis  ceases  to  be  duly  performed,  the  lungs  become  en- 
gorged, and  dqath  supervenes  at  the  end  of  a few  days,  may  not  the  fact  I have 
just  cited  be  classed  among  this  order  of  facts  ? There  was  here  also  a gradual 
diminution,  and  ultimately  a cessation  of  the  influence  exercised  by  the  eighth 
pair  on  the  change  of  venous  into  arterial  blood,  thence  the  constantly  increasing 
dyspnoea,  etc.  If  this  cause  of  dyspnoea  will  not  be  admitted,  it  will  then  be 
necessary  to  allow  that  the  very  great  embarrassment  of  the  respiration  pre- 
sented by  this  patient  existed  without  our  being  able  to  detect  in  the  dead  body 
any  lesion  which  could  account  for  it ; for  I do  not  think  that  the  tubercles, 
which  were  very  small  and  very  few  in  number,  as  found  in  the  lungs,  could  in 
any  way  explain  this  dyspnoea,  which  for  its  intensity  may  be  compared  to  that 
which  occurs  in  the  progress  of  the  most  serious  organic  diseases  of  the  heart. 


DISEASES  OF  THE  ABDOMEN. 


333 


SECTION  III. 

DISTURBANCES  OF  THE  SECRETIONS  AND  OF  NUTRITION. 

27.  The  secretion  of  urine  is  that  most  frequently  altered  in  diseases  of  the 
liver.  The  most  remarkable  of  these  alterations  consists  in  the  mixture  of  several 
elements  of  the  bile  with  the  ordinary  principles  of  the  urine.  Physiology 
teaches  us  that  among  the  different  ways  in  which  different  foreign  substances 
may  be  eliminated  from  the  body,  none  is  more  active  or  more  open  than  the 
renal  apparatus.  In  icteric  patients  also  the  urine  contains  bile  before  the  skin 
is  coloured  yellow  ; it  happens  even  in  more  than  one  case  of  liver  disease,  that 
the  skin  does  not  lose  its  natural  colour,  whilst  the  tint  acquired  by  the  urine 
attests  the  presence  of  bile  in  the  liquid.  What  is  there  astonishing  in  seeing 
the  materials  of  the  bile,  which  the  liver  no  longer  separates  from  the  blood, 
make  their  exit  from  the  system  with  the  urea,  when  we  constantly  see  a great 
number  of  substances  not  assimilable  expelled  with  the  same  principle — sub- 
stances what  have  been  either  formed  in  the  system,  or  have  been  introduced 
from  without  ? 

The  materials  of  the  bile,  when  they  are  not  sufficiently  separated  from  the  blood 
by  their  ordinary  eliminating  organ,  may  again  escape  from  the  system  by  other 
passages  than  the  kidneys.  Oftentimes,  for  instance,  the  matter  of  the  cutaneous 
transpiration  is  impregnated  with  them,  and  if  the  patients  sweat,  their  linen 
assumes  a yellow  tinge. 

The  mucus  has  appeared  to  us  to  contain  bile,  or  at  least  its  elements,  much  less 
frequently  than  the  urine  and  sweat.  The  lingual  mucus,  for  instance,  is  not  more 
frequently  yellow  incases  of  jaundice  than  in  any  other  affection.  Once,  however, 
in  a jaundiced  individual,  we  found  an  extraordinary  colouring  of  this  mucus,  and 
of  that  supplied  by  the  membrane  of  the  air  passages  ; the  upper  surface  of  the 
tongue  was  covered  by  a thick  coat  of  a fine  green  tint ; the  mucus  expectorated 
presented  the  same  colour.  The  conjunctivae  and  skin  were  yellow  as  usual; 
the  urine  also  presented  the  orange  red  tint  usual  to  it  in  cases  of  jaundice. 
What  was  the  cause  of  this  extraordinary  difference  between  the  colour  of  the 
matter  accidentally  mixed  with  the  products  of  the  secretion  of  the  mucous  mem- 
branes, and  the  colour  of  that  which  impregnated  the  reticular  tissue  of  the  skin, 
and  which  tinged  the  urine  ? 

To  any  person  who  has  studied  these  facts,  it  becomes  very  probable  that  in  a 
certain  number  of  diseases  whose  cause  seems  to  reside  in  a morbid  matter  which 
exists  in  the  blood,  whether  it  may  have  been  introduced  from  without,  or  may 
have  been  formed  in  it,  the  secreting  organ  perform  the  important  part  of  sepa- 
rating from  the  blood  the  principles  which  alter  it.  It  is  not  in  this  way,  for 
instance,  that  we  may  account  for  the  remarkable  fetor  of  the  cutaneous  secre- 
tions, intestinal  and  urinary,  in  animals  who  have  received  putrid  matter  into 
their  veins?  What  is  that  characteristic  acid  odour  in  the  sweat  of  lying-in 
women  during  the  milk  fever?  It  is  very  evident  that  this  can  depend  only  on 
a new  principle  which  is  mixed  up  with  the  cutaneous  exhalation,  and  which 
is  .indicated  here  by  its  odour,  as  it  is  indicated  in  icteric  patients  by  its  colour. 
Is  not  this  principle  one  of  those  which  must  enter  into  the  composition  of  the 
milk?  A supplementary  secretion  separates  it  from  the  mass  of  the  blood 
where  it  is  formed,  until  the  mammae  are  sufficiently  prepared  to  eliminate  it. 
What  is  the  result?  this,  that  if  the  mammary  gland  does  not  dischargeits  func- 
tion properly,  the  materials  of  the  milky  secretion  will  remain  in  the  blood  from 
which  they  must  be  eliminated,  as  we  have  seen  the  materials  of  the  bile  were, 
and  as  the  principles  of  the  urine  are  under  other  circumstances,  by  other  exits 


334 


ANDRAL’S  MEDICAL  CLINIC. 


than  the  kidneys.  If  we  admit  these  facts,  we  have  only  to  allow  the  conse- 
quences, by  also  admitting  either  the  mixture  of  the  principles  of  the  milk  with 
the  different  secreted  liquids,  or  even  their  stagnation  and  deposition  in  certain 
organs,  on  the  surface  of  serous  membranes  or  elsewhere  ; and  in  order  to 
favour  their  elimination,  may  not  a process  of  irritation  more  or  less  danger- 
ous be  set  up  there  ? and  if  such  be  the  cause  of  the  latter,  shall  bloodletting, 
under  such  circumstances,  be  an  efficacious  mode  of  treatment?  would  it  not 
be  more  rational,  and  more  physiological,  to  stimulate  some  secretion,  as,  for 
instance,  that  of  the  liver,  or  of  the  intestinal  mucous  membrane  ? Is  it  in  this 
way  that  the  purgative  treatment  employed  by  Doublet  and  other  physicians 
acted  in  the  cases  of  what  are  called  puerperal  fevers  ? There  was  something 
then  not  altogether  unreasonable  in  the  old  belief  \\\  milky  metastases. 

We  beg  the  reader  to  observe  that  we  do  not  give  any  of  those  ideas  as 
proved,  we  only  require  that  they  should  be  reflected  on,  because  more  than  one 
fact,  both  physiological  and  pathological,  really  tends  to  demonstrate  its  accuracy, 
and  because  an  opinion  abandoned  is  not  necessarily  for  that  reason  a false 
opinion. 

28.  Nutrition,  properly  so-called,  is  seriously  altered  in  most  cases  of 
chronic  diseases  of  the  liver.  However,  we  seldom  observe  that  extreme 
marasmus  which  accompanies  pulmonary  phthisis.  There  is  even  an  acci- 
dental production  whose  development  in  the  liver  very  rarely  produces  any 
wasting,  unless  it  has  attacked  a very  considerable  portion  of  the  hepatic  paren- 
chyma, namely  hydatids.  An  abscess  of  small  extent,  a cancerous  mass  of  in- 
considerable size,  oftentimes  even  a mere  change  in  the  size  or  consistence  of 
the  liver,  occasion  greater  disturbance  in  the  process  of  nutrition  than  those 
entozoaires  do. 

Diseases  of  the  liver,  whether  acute  or  chronic,  may  also  modify  the  functions 
of  animal  life,  as  well  as  those  of  nutritive  life ; but  here  nothing  can  be  laid 
down  in  a general  way  ; for  there  are  as  many  modifications  of  the  innervation 
as  there  are  individuals.  There  are  some  patients  in  whom  the  nervous  system 
remains  in  its  normal  state,  whatever  be  the  disorganisation  which  the  liver 
has  undergone.  In  others  the  least  irritation  of  this  organ  reacts  on  the  encepha- 
lon ; it  gives  rise  to  these  different  groups  of  symptoms,  which  constitute  ataxic 
fever.  In  their  chronic  state  it  may  happen  that  affections  of  the  liver,  at  the 
same  time  that  they  are  indicated  only  by  very  slightly  marked  local  symptoms, 
may  produce  by  their  sympathetic  action  on  the  nervous  centres,  a crowd  of 
morbid  phenomena,  which  may  very  properly  be  classed  under  the  neuroses, 
their  seat  being  in  the  nervous  system,  the  real  origin  of  which,  however,  is 
the  affection  of  the  liver. 


CHAPTER  III. 

CASES. 

29.  Whatever  exactness  we  may  have  endeavoured  to  attain  in  the  general 
description  which  we  have  now  given  of  diseases  of  the  liver,  we  are  fully 
sensible  how  far  what  we  have  said  is  from  representing  those  infinite  shades 
which  these  diseases  may  present  in  their  anatomical  characters,  in  their  symp- 
toms, their  progress,  complications,  etc.  This  end  cannot  be  attained  without 
studying  a certain  number  of  cases,  a study  which  is  oftentimes  painful,  but 
always  useful. 


DISEASES  of  the  abdomen. 


335 


ARTICLE  I. 

CASES  OF  SANGUINEOUS  CONGESTIONS  OF  THE  LIVER. 

Case  1. — Organic  affection  of  the  heart — Tumour  in  the  right  hypochondrium,  the  appearance 
of  which  coincided  with  every  increase  of  the  dyspnoea — Liver  very  large  and  gorged  with 
blood. 

A man,  46  years  of  age,  stated  that  he  had  been  asthmatic  from  his  youth. 
Only  about  one  year  before  we  saw  him  he  perceived  some  oedema  around  the 
ankles;  this  oedema  involved  by  degrees  the  entire  of  the  lower  extremities, 
proceeding  from  below  upwards  ; subsequently  the  scrotum,  and  ultimately  the 
abdomen,  became  tumefied.  After  lasting  for  three  months  this  dropsy  disap- 
peared ; but  it  reappeared  two  months  before  the  patient’s  admission  into  the 
Charite  ; the  dropsy  was  then  almost  general  over  the  subcutaneous  cellular 
tissue  ; the  ascites  was  not  very  great;  the  respiration  was  very  much  impeded, 
the  only  position  in  which  the  patient  could  remain  was  that  of  sitting.  The 
pulsations  of  the  heart  were  but  slightly  heard,  and  with  great  irregularity  in  their 
rhythm,  in  the  praecordial  region,  along  the  entire  extent  of  the  sternum,  and  in 
the  epigastrium ; the  pulse  was  scarcely  felt ; several  pulsations  of  the  heart 
were  frequently  heard  in  regular  succession  without  its  being  possible  to  perceive 
the  arterial  pulsations.  The  right  hypochondrium  was  tense,  without  being 
painful.  We  discovered  there  a rounded  body,  which,  appearing  to  commence 
from  behind  the  ribs,  terminated  in  a blunt  sort  of  border  a little  above  the  um- 
bilical region.  M.  Lerminier  directed  sixteen  ounces  of  blood  to  be  taken  from 
the  arm,  and  twenty  leeches  to  be  applied  to  the  anus.  According  as  the  blood 
flowed  from  the  vein,  the  patient  seemed  to  revive  ; his  breathing  became  freer, 
and  the  pulse  improved.  On  the  next  morning  this  person,  who  the  day  before 
appeared  to  be  dying,  was  no  longer  the  same.  The  livid  colour  of  the  face 
was  gone  ; the  pulse  had  again  become  regular  and  sufficiently  strong ; the 
pulsations  of  the  heart  were  heard  to  be  more  distinct.  An  evident  change  had 
taken  place  at  the  same  time  in  the  right  hypochondrium,  it  was  again  soft  and 
no  tumour  was  felt.  This  improved  state  continued  without  variation  for  the 
three  following  weeks  ; no  change  in  the  dropsy.  But  after  this  time,  and  with- 
out any  known  cause,  the  difficulty  of  breathing  again  became  very  great ; pulse 
very  weak  and  irregular;  countenance  assumed  a livid  tint,  and  at  the  same 
time  the  liver  once  more  descended  into  the  hypochondrium,  where  it  became 
as  perceptible  as  before.  Bloodletting  was  again  employed,  but  not  with  the 
same  success  as  on  the  former  occasion  ; the  state  of  asphyxia  became  more  and 
more  marked,  and  the  patient  died. 

Post-mortem. — Purple  tint  of  the  countenance  was  retained  even  after  death  ; 
arms  and  legs  livid.  Black  blood,  like  currant-jelly,  distended  the  four  cavities 
of  the  heart.  The  enlarged  cavity  of  the  right  ventricle  when  emptied  of  its 
blood  did  not  collapse  ; its  parietes  were  hypertrophied.  The  cavity  of  the 
left  ventricle  was  also  very  large,  and  the  thickness  of  its  parietes  very  great. 
The  different  orifices  of  the  heart  were  free.  Some  small  white  spots  were 
found  on  the  internal  surface  of  the  aorta.  The  lungs  were  infarcted,  but 
healthy. 

In  the  abdomen,  the  liver  was  very  large  ; it  passed  several  fingers  breadth 
beyond  the  cartilaginous  edges  of  the  ribs  ; by  incision  and  slight  pressure  an 
enormous  quantity  of  blood  was  made  to  flow  from  it.  Its  tissue,  which  was 
of  the  ordinary  consistence,  presented  an  almost  uniform  red  tint,  deeper  how- 
ever where  the  substance  naturally  exists  which  we  have  called  spongy  or 
cavernous,  and  which  appears  to  be  peculiarly  vascular.  The  gall-bladder  con- 


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ANDRAL’S  MEDICAL  CLINIC. 


tained  a small  quantity  of  yellow  bile.  All  the  tissues  were  in  general  gorged 
with  blood. 

This  case  furnishes  a striking  example  of  one  of  those  sanguineous  conges- 
tions entirely  mechanical,  of  which  the  liver  may  become  the  seat  in  persons 
labouring  under  an  organic  affection  of  the  heart.  In  the  most  vascular  part  of 
the  liver  all  the  blood  goes  on  accumulating,  which,  being  conveyed  to  this 
organ  by  the  vena  portae,  cannot  pass  into  the  heart,  and  from  this  latter  organ 
also  there  may  be  a reflux  of  a certain  quantity.  Then  the  liver  becomes  tume- 
fied, just,  for  instance,  as  we  see  the  corpora  cavernosa  penis  become  swollen 
in  individuals  who  have  been  strangled.  What  is  very  remarkable  is  the  ex- 
treme rapidity  with  which,  on  the  one  hand,  the  liver  may  acquire  a prodigious 
size,  and  with  which,  on  the  other  hand,  it  resumes  its  normal  size,  as  soon  as 
the  obstruction  to  the  venous  circulation  has  been  diminished.  This  real  dimi- 
nution of  the  liver  was  here  very  evident  after  the  first  bleeding. 

Case  2. — Active  sanguineous  congestion  of  the  liver,  without  alteration  of  its  texture  (first 

degree  of  acute  hepatitis). — jaundice  accompanied  with  fever — Tumour  in  the  right  hypo- 

chondrium — Sympathetic  irritation  of  the  brain. 

A middle-aged  man,  of  a strong  constitution,  skin  brown,  hair  black,  was 
labouring  under  jaundice  with  fever  when  he  entered  the  Charite.  Eight  days 
before,  his  health,  which  till  then  was  good,  became  deranged.  He  first  felt  a 
sort  of  weight  towards  the  right  hypochondrium.  The  physician  who  was  then 
consulted,  detected  a tumour  in  this  hypochondrium,  and  fever  soon  supervened. 
The  patient  was  bled.  When  we  saw  him  he  had  a well  marked  jaundice, 
which  commenced  only  since  the  last  three  days  ; pulse  frequent,  skin  hot. 
he  complained  of  no  pain;  b.ut  on  examining  the  abdomen  the  liver  was  found 
to  be  enlarged  in  the  right  hypochondrium.  The  tumour  which  it  formed  ex- 
tended from  the  cartilaginous  edge  of  the  ribs,  behind  which  it  seemed  to  ex- 
tend, to  a little  distance  above  the  umbilicus:  the  edge  of  this  organ  was  very 
easily  circumscribed  ; the  tumour  did  not  go  beyond  the  linea  alba  : it  occa- 
sioned no  pain  even  on  pressure.  The  tongue  was  whitish,  without  any  red 
points  ; no  bitter  taste  in  the  mouth  ; the  appetite  was  lost,  thirst  considerable, 
epigastrium  free  from  pain,  stools  natural.  Urine  rather  scanty,  and  of  a re- 
markable orange-yellow  colour.  This  person  was  considered  to  laboqr  under 
acute  hepatitis.  (Twenty-five  leeches  to  the  anus  ; emollient  ptisans.) 

During  the  five  days  following  the  state  of  the  patient  remained  nearly  the 
same.  Fever  was  high,  and  there  was  some  delirium  every  night.  On  the 
morning  of  the  7th  day,  dating  from  the  time  of  his  admission,  the  delirium  of 
the  night  still  continued  ; he  fixed  his  eyes  on  those  who  stood  around  him, 
without  answering  their  questions  ; he  then  spoke  to  himself,  and  in  a very 
incoherent  manner.  Face  was  red,  eyes  injected ; pulse  from  115  to  120  ; skin 
burning  hot  and  dry  ; icteric  tint  more  marked  than  ever.  (Twenty  leeches 
along  each  jugular  vein  ; sinapisms  to  the  legs  ; lavement  with  an  ounce  of 
sulphate  of  soda.) 

In  the  course  of  the  day,  there  was  alternately  profound  coma  and  violent 
agitation,  during  which  he  sent  forth  a piercing  cry  occasionally,  which  seemed 
to  indicate  acute  suffering,  whether  real  or  imaginary.  In  the  evening  the 
pupil  on  duty  obtained,  with  difficulty,  three  pallettes  of  blood  from  him.  The 
blood,  when  taken,  collected  into  a small  dense  coagulum,  which  was  covered 
with  a buflfy  coat  of  considerable  thickness.  Still,  on  the  two  following  days, 
the  cerebral  symptoms  continued  with  the  same  intensity  and  in  the  same  form  ; 
they  then  suddenly  changed  character;  the  state  of  coma  became  continued  ; 
the  patient  fell  into  a state  of  stupor  from  which  nothing  could  arouse  him.  The 
extremities,  when  raised,  fell  again  by  their  own  weight ; still  the  skin  cover- 


DISEASE'S  OF  THE  ABDOMEN. 


337 


ing  them  retained  its  sensibility,  and  the  power  of  muscular  contraction  was  not 
destroyed.  The  tumour  in  the  right  hypochondrium  still  continued  ; same 
state  of  pulse;  and  the  jaundice  still  continued.  The  lungs,  however,  soon 
became  engorged,  the  respiration  was  accompanied  with  a rale,  and  the  patient 
died  in  a sort  of  apoplectic  state,  on  the  12th  day  after  his  admission,  and  the 
20th  day  after  the  appearance  of  the  first  morbid  symptoms.  During  the  last 
three  days  blisters  were  applied  to  the  lower  extremities,  and  one  also  to  the 
nucha. 

Post-mortem.  The  cerebral  membranes  were  considerably  injected,  and 
from  the  Substance  of  the  brain,  when  sliced,  drops  of  blood  were  seen  to  escape 
through  several  small  points,  the  orifices  of  so  many  vessels.  The  encephalon 
and  its  membranes  were  then  the  seat  of  considerable  sanguineous  congestion  ; 
yet  we  have  several  times  observed  a similar  congestion  in  persons  whose  ner- 
vous system  presented  no  functional  disturbance.  Very  little  serum  was  effused 
into  the  ventricles  and  at  the  base  of  the  cranium.  The  different  parts  of  the 
encephalon  were  examined  with  the  greatest  care  ; nothing,  however,  was  dis- 
covered there,  nor  in  the  spinal  cord.  Nothing  remarkable  in  the  thoracic 
organs,  except  considerable  serous  engorgement  of  the  lungs. 

The  first  object  which  struck  us,  on  opening  the  abdomen,  was  the  size  of  the 
liver.  It  passed  beyond  the  edge  of  the  ribs  by  several  fingers’  breadth.  When 
seen  externally,  it  was  of  a bright  red  colour.  Each  incision  made  in  it  caused 
a considerable  quantity  of  blood  to  escape  from  it.  Nothing  else  remarkable 
was  observed  in  the  abdominal  viscera,  except  some  injected  veins  which 
traversed  in  great  numbers  the  submucous  cellular  tissue  of  the  stomach,  and 
different  parts  of  the  small  intestine.  There  were  also  large  veins  gorged  with 
the  blood  in  the  mesentery.  The  cartilages  of  the  ribs,  the  fibrous  membranes 
of  the  encephalon,  heart,  and  spleen,  the  liquid  contained  in  the  thoracic  duct, 
presented  a well  marked  yellow  tint.  This  tint  was  observed,  though  in  a less 
degree,  on  the  external  surface  of  the  intestines. 

The  disease,  whose  history  has  been  now  detailed,  presents  two  distinct 
periods  for  consideration.  The  first  is  marked  by  the  local  and  general  symp- 
toms of  an  acute  affection  of  the  liver  ; in  the  second,  very  serious  nervous 
symptoms  appear.  In  the  first  period  there  was  tumefaction  of  the  liver,  fever, 
and  jaundice;  there  was  no  pain,  nor  was  any  symptom  observed  which  could 
induce  us  to  suspect  that  the  affection  of  the  liver  was  consecutive  on  any  lesion 
of  the  digestive  tube  ; and,  after  death,  this  tube  was  found  perfectly  healthy. 
Neither  was  there  anything  found  in  the  biliary  ducts,  which  could  account  for 
the  jaundice.  Could  this  have  been  produced  by  the  great  sanguineous  conges- 
tion of  which  the  liver  was  the  seat  ? During  life  we  had  the  certainty  that  the 
excretory  ducts  of  the  bile  were  equally  free,  for  the  stools  were  constantly 
tinged  with  yellow.  Here,  then,  is  a case  which  demonstrates  the  possibility 
of  the  production  of  jaundice  without  previous  production  of  obstruction  in  the 
ductus  hepaticus  or  choledochus. 

Before  the  nervous  symptoms  of  the  second  period  were  very  well  marked, 
there  was  for  several  nights  intermittent  delirium,  which  seemed  to  depend  on 
a sympathetic  irritation,  of  which  the  brain  became  periodically  the  seat.  Death 
was  evidently  th§  result  of  this  irritation,  which  was  now  become  continued. 
There  was  at  first  an  exaltation,  then  a total  abolition  of  the  innervation;  and 
it  was  when  the  nervous  influence  ceased  to  act,  in  its  normal  way,  on  the 
lungs,  that  engorgement  of  the  latter  organs  preceded  for  a little  time  the 
extinction  of  life.  Still,  what  do  we  find  to  account  for  all  these  serious  symp- 
toms, to  explain  to  us  that  remarkable  disturbance  in  the  action  of  the  nervous 
centres  ? A little  more  blood  than  ordinary  in  the  vessels  of  the  brain  and  its 
investing  membranes  ; a little  more  blood  than  oYdinary  also  investing  the  ves- 
sels of  the  liver,  and  nothing  else  ! Very  frequently  such  congestions  are  met, 
29 


338 


ANDRAL’S  MEDICAL  CLINIC. 


and  nothing  similar  in  the  symptoms.  Still  we  can  hardly  refuse  believing  that 
in  this  particular  case  the  latter  depended  on  this  congestion  ; the  sanguineous 
congestion  of  the  liver  having  commenced  with  jaundice  and  fever,  being  indi- 
cated during  life  by  tumefaction  of  the  hypochondrium,  seemed  to  have  pro- 
duced both  this  jaundice  and  fever;  the  nightly  delirium  at  first  seemed  also  to 
depend  on  it ; and  if  this  opinion  is  considered  as  well-founded,  the  consequence 
must  be  admitted,  namely,  that  a further  degree  of  sympathetic  irritation  of  the 
encephalon  was  sufficient  to  produce  all  those  further  nervous  disturbances. 
But,  behind  this  visible  part  of  the  phenomena,  their  proximate  and  immediate 
cause  lies  concealed,  and  we,  in  our  ignorance,  designate  it  by  the  name  of 
idiosyncrasy,  or  of  individual  disposition.  It  is  this  unequal  force  of  vital 
resistance  by  which  those  infinitely  varying  effects  can  be  explained,  produced 
by  one  and  the  same  lesion.  The  slightest  lesion  may  react  on  all  points  of  the 
system  and  produce  death  ; the  most  serious,  with  respect  to  organic  disturb- 
ances, may  not  produce  any  important  disturbance  of  the  functions.  The 
opinion  which  we  now  give  has  recently  received  support  from  an  excellent 
article  of  M.  Louis,  on  unforeseen  and  sudden  deaths.  We  should  then  commit 
serious  and  continual  mistakes,  if  from  the  lesions  found  on  a dead  body  we 
should  attempt  to  divine  the  symptoms  which  took  place  during  life.  Such 
calculations  would,  in  many  instances,  prove  very  erroneous. 

A considerable  number  of  cases  warrant  us  in  thinking  that  active  sanguineous 
congestions  of  the  liver,  such  as  that  last  detailed,  are  not  very  rare,  whether  as 
primary  diseases,  or  as  consecutive  on  other  affections,  and  particularly  on  an 
inflammation  of  the  digestive  tube.  They  are  indicated  sometimes  by  mere 
tumefaction  of  the  liver,  with  or  without  fever;  sometimes  by  these  same 
symptoms,  and  further  by  jaundice,  seldom  by  pain.  We  have  seen  many 
individuals  in  whom  these  several  symptoms  lasted  but  a very  little  time,  and 
after  their  disappearance  the  health  was  perfectly  re-established.  In  others 
there  was  an  extraordinary  disposition  to  the  return  of  these  hepatic  congestions. 
We  have  had  an  opportunity  of  observing,  among  others,  a young  man  in  whom 
for  the  space  of  two  years  the  hypochondrium  became,  five  or  six  times  at  least, 
the  seat  of  a tumour  which,  by  reason  of  its  form  and  situation,  should  be  con- 
sidered as  appertaining  to  the  tumefied  liver.  At  the  same  time  fever  set  in  ; 
twice  only  he  had  jaundice.  This  tumefaction  of  the  right  hypochondrium 
sometimes  lasted  for  some  days  only,  sometimes  from  fifteen  days  to  three 
weeks.  Each  time  advantage  was  derived  from  the  application  of  leeches  over 
the  hypochondrium.  These  hepatic  congestions  finally  disappeared,  and  there 
was  no  reason  to  suppose  that  they  left  any  trace  of  organic  affection  in  the  liver. 
At  other  times  the  same  congestions  may  really  appear  under  a chronic  form, 
remain  continued  for  a very  longtime,  without  the  liver,  when  examined  after 
death,  presenting  any  other  alteration  than  an  unusual  accumulation  of  blood  in 
its  parenchyma. 

Case  3. — Jaundice  and  painful  tumefaction  of  the  right  hypochondrium,  continuing  for  more 

than  a year — No  other  alteration  of  the  biliary  apparatus  except  sanguineous  engorgement 

of  the  liver — Chronic  duodenitis — Acute  entero-colitis. 

A woman,  thirty-five  years  of  age,  entered  the  Charite  with  jaundice.  She 
gave  the  following  account  of  the  origin  of  her  illness.  Since  the  last  three 
years  she  experienced  from  time  to  time  a loss  of  appetite,  bitter  taste  in  the 
mouth,  sense  of  weight  in  the  epigastrium,  and  general  lassitude.  She  took  a 
vomit  which  removed  these  symptoms  ; but  they  soon  returned,  and  were  again 
treated  in  the  same  way,  or  by  purgatives.  About  a year  ago,  having  experi- 
enced the  same  symptoms,  she  took  two  grains  of  tartar  emetic,  which  made 
her  worse ; her  loss  of  appetite  increased,  an  acute  pain  was  felt  towards  the 
right  of  the  epigastrium,  and  a few  days  after  she  found  her  skin  of  a yellow 


DISEASES  OF  TIIE  ABDOMEN. 


339 


colour.  Iler  physician  then  applied  fifteen  leeches  to  the  anus,  and  adminis- 
tered medicines,  the  nature  of  which  she  knew  not.  During  the  time  which 
intervened  between  the  appearance  of  the  jaundice  and  her  admission  into  the 
Charite,  she  wasted  away  more  and  more  ; the  yellowness  of  the  skin  continued  ; 
the  pain  on  the  right  of  the  epigastrium  was  but  temporary,  but  it  was  succeeded 
by  a sensation  of  weight  in  the  right  hypochondrium,  which  the  patient  said 
she  felt  to  be  more  tense  and  swollen  than  the  left.  From  time  to  time,  the 
mere  sensation  of  weight  which  she  referred  to  became  changed  into  a pain 
more  or  less  acute.  The  patient  had  neither  nausea  nor  vomiting,  but  an  habi- 
tual dislike  for  food  ; still  whatever  nutriment  she  took,  whether  solid  or  liquid, 
produced  no  pain.  Her  stools  were  not  at  any  time  devoid  of  colour.  They 
were  in  general  scanty,  and  variable  in  their  consistence.  When  we  saw  this 
woman  we  were  struck  at  her  extreme  state  of  emaciation.  The  jaundice  was 
very  marked  ; the  conjunctivae  were  of  a bright  yellow.  We  discovered  a degree 
of  tension  in  the  right  hypochondrium,  which  did  not  at  all  exist  in  the  left ; pres- 
sure was  painful  on  this  part,  and  we  were  unable  accurately  to  circumscribe 
any  tumour  here.  The  remainder  of  the  abdomen  was  soft  and  free  from  pain. 
There  was  complete  anorexia,  no  thirst,  tongue  pale,  without  any  coating ; 
alvine  evacuations  of  a yellow  colour.  The  pulse  became  a little  frequent 
towards  evening,  and  then  the  temperature  of  the  skin  was  a little  raised.  The 
urine  was  scanty,  and  of  a beautiful  orange-yellow  colour. 

The  very  long  time  the  jaundice  had  continued,  the  progressive  wasting  of 
the  patient,  the  painful  swelling  of  the  right  hypochondrium,  seemed  to  indicate 
a serious  affection  of  the  liver,  probably  a cancerous  degeneration  of  this  organ. 
The  nature  of  the  stools  satisfied  us  that  there  was  no  obstruction  of  the  bile 
ducts.  The  preceding  circumstances  seemed  to  indicate  also  an  accompanying 
affection  of  the  stomach,  or  rather  of  the  upper  portion  of  the  small  intestine. 
The  region  of  the  liver  was  directed  to  be  rubbed  with  a mixture  of  calomel  and 
axunge.  After  a month,  profuse  diarrhoea  set  in,  which,  during  the  first  four 
days  of  its  existence,  resisted  all  treatment ; but  on  the  fifth  day  the  abdomen 
became  tympanitic,  the  pulse  was  now  habitually  frequent,  the  temperature  of 
tlje  skin  was  raised.  On  the  seventh  and  eighth  days  there  was  constant  fever, 
alvine  evacuations  very  frequent  and  involuntary,  great  prostration  of  strength, 
features  very  much  altered,  speech  now  embarrassed,  tongue  dry,  brown  at  its 
centre,  no  redness  at  its  edges.  Died  on  the  ninth  day. 

Post-mortem.  The  dura  mater  and  external  surface  of  the  brain  of  a very 
marked  yellow  colour.  A very  small  quantity  of  serum  effused  into  the  peri- 
cardium presented  the  same  yellow  colour.  The  heart  contained  some  fibrinous 
coagula  divested  of  colouring  matter.  The  serum  contained  in  the  thoracic 
duct  was  also  yellow.  The  same  colour  presented  itself  on  the  external  surface 
of  the  different  parts  contained  in  the  abdomen.  The  internal  surface  of  the 
stomach  was  pale.  Mucous  membrane  healthy ; large  veins  full  of  blood  were 
seen  to  pass  beneath  it.  All  the  inner  surface  of  the  duodenum,  from  the  pylo- 
ric valve  inclusively  to  as  far  as  the  commencement  of  the  jejunum,  presented 
a well-marked  brownish  red  tint.  The  follicles  of  the  duodenum,  usually  very 
large,  were  here  much  more  so  than  usual.  The  mucous  membrane  of  this  part 
was  very  much  thickened,  and  friable.  Nothing  morbid  in  the  biliary  ducts. 
The  liver  was  remarkable  for  its  size  : it  descended  considerably  below  the 
cartilaginous  edge  of  the  ribs,  and  its  left  lobe  touched  the  spleen.  The  upper 
four-fifths  of  the  small  intestine  were  healthy  ; but  at  the  lower  fifth  the  mucous 
membrane  was  very  much  injected.  This  injection  was  also  perceptible  on 
the  two  surfaces  of  the  ileo-caecal  valve  and  the  interior  of  the  caecum.  It 
diminished  in  the  ascending  colon,  and  then  reappeared  in  the  sigmoid  flexure 
and  in  the  rectum. 

Here  again  is  a case  where  to  account  for  serious  symptoms  of  considerable 


340 


ANDRAL’S  MEDICAL  CLINIC. 


duration,  we  find  lesions  apparently  very  slight,  which  a superficial  examination 
might  have  passed  over.  To  account  for  a jaundice  of  one  year’s  duration, 
for  a disturbed  digestion  of  a still  longer  standing,  for  a progressive  wasting, 
for  a febrile  accession  which  was  lighted  up  every  evening,  and  lastly,  for  an 
adynamic  fever  of  which  the  patient  died,  nothing  was  found  but  a liver  a little 
larger  than  usual,  and  a brown  or  red  colouring  of  a small  portion  of  the  diges- 
tive tube.  Let  us  see,  however,  whether  we  shall  not  be  able  to  establish  a 
correspondence  between  these  lesions  and  the  symptoms  observed  during  life. 
Is  it  not  to  the  existence  of  a chronic  inflammation  of  the  duodenum  that  the 
signs  of  gastric  disturbances  were  attributable,  which  the  patient  complained  of 
occasionally,  before  becoming  jaundiced  ? Is  it  not  this  chronic  duodenitis 
which,  having  been  exasperated  by  the  last  emetic  which  the  patient  took,  ex- 
tended to  the  liver,  and  thus  produced  the  jaundice.  The  sanguineous  conges- 
tion of  the  liver  became  chronic,  as  the  duodenitis  which  had  occasioned  it. 
Under  the  influence  of  this  twofold  lesion,  the  patient  continued  to  waste  away  ; 
she  would  not  have  presented  more  serious  symptoms,  if,  for  instance,  she  had 
been  attacked  with  cancerous  degeneration  of  both  the  stomach  and  liver. 
Therefore,  we  still  repeat  it,  the  severity  and  nature  of  the  symptoms  often 
depend  much  less  on  the  severity  and  nature  of  the  lesions  than  on  the  various 
dispositions  of  the  individuals  in  whom  these  latter,supervene,  on  the  degree  of 
sensibility  of  the  patients,  on  the  sympathies  more  or  less  numerous,  more  or 
less  active,  which  come  into  play  ; besides  we  must  not  here  confine  ourselves 
merely  to  phenomena  of  this  order;  it  must  not  be  forgotten  that  it  is  in  the 
duodenum  that  the  chyme  maybe  changed  into  nutritive  matter.  Now,  if  this 
intestine  is  in  a state  of  chronic  inflammation,  can  chylifaction  continue  to  go 
on  ? This  is  scarcely  probable  ; and  there  is  again  a powerful  cause  of  wasting. 
The  bad  state  of  nutrition  in  this  patient  appeared  such  as  would  gradually 
bring  her  to  the  grave,  when  a new  acute  inflammation  of  another  portion  of 
the  intestine  supervened.  The  diarrhoea  which  indicated  it  at  first,  was  soon 
followed  by  more  serious  symptoms,  and  the  patient  died  in  the  midst  of  what 
is  called  adynamic  fever,  which,  evidently  in  this  case,  was  symptomatic  of  the 
entero-colitis.  Besides,  we  think  that  any  other  acute  inflammation  superven- 
ing under  such  circumstances  in  an  individual  whose  nutrition  and  innervation 
had  been  for  a long  time  altered  by  chronic  disease,  any  acute  inflammation, 
we  say,  would  have  occasioned  those  same  symptoms  of  adynamic  fever. 

It  is  now  a well-ascertained  fact,  that  the  diseases  called  bad  fevers  depend 
less  on  the  intensity  of  the  local  inflammation,  than  on  the  dispositions  in  which 
this  inflammation  finds  the  individuals  whom  it  attacks. 

In  this  case,  again,  the  jaundice  was  independent  of  all  obstruction  of  the  bile 
ducts,  and  it  would  indeed  be  a very  difficult  matter  to  account  satisfactorily  for 
its  production.  How  could  the  twofold  chronic  inflammation  of  the  duodenum 
and  liver  have  continued  for  so  long  a time  without  producing  any  disorganisa- 
tion in  these  parts  ; whilst  in  other  individuals  sanguineous  congestion,  very 
inconsiderable  in  intensity  and  duration,  is  rapidly  followed  by  the  most  serious 
changes  of  nutrition  or  secretion  ? Be  this  as  it  may,  we  may  easily  conceive 
that  where  there  is  as  yet  no  disorganisation,  a cure  is  possible,  however  im- 
probable it  may  appear  by  reason  of  the  long  duration  of  the  disease.  The 
subject  of  the  following  case,  who  presented  symptoms  very  closely  resembling 
those  of  the  patient  just  mentioned,  recovered  perfectly. 

Case  4. — Jaundice  with  tumour  in  the  right  hypochondrium — Hectic  fever,  wasting  away  for 

fifteen  months — Recovery. 

A mechanic,  about  thirty-nine  years  of  age,  experienced  for  nearly  a year  be- 
fore entering  the  Charite  a dull  pain  in  the  lower  part  of  the  chest.  At  the  same 


DISEASES  OF  THE  ABDOMEN. 


341 


time  there  was  general  indisposition,  great  prostration,  and  loss  of  appetite.  An 
application  of  leeches  to  the  epigastrium  removed  these  symptoms,  and  the 
patient  thought  himself  restored  to  health.  However,  on  the  following  days, 
the  appetite,  which  had  returned  for  a time,  disappeared  again,  and  soon  after 
the  eyes,  and  then  the  skin,  became  yellow.  The  patient  could  give  but  a 
very  imperfect  account  of  his  subsequent  symptoms  and  of  the  treatment.  The 
jaundice  continued  for  the  eleven  months  following  ; the  appetite  never  returned, 
some  diarrhoea  occurred  from  time  to  time,  and  at  intervals  some  pains  were 
felt  in  the  right  hypochondrium.  Great  emaciation  followed.  Up  to  this  period 
no  regular  treatment  had  been  adopted.  When  we  first  saw  this  patient  we 
formed  a very  unfavourable  prognosis  on  him.  He  was  now  in  a state  of 
marasmus  ; a slight  febrile  disturbance  took  place  every  night,  and  during  the 
day  the  pulse  lost  nothing  of  its  frequency.  The  jaundice  was  very  strongly 
marked  over  the  entire  cutaneous  surface.  On  examining  the  abdomen  we 
discovered  an  unusual  swelling  in  the  right  hypochondrium  and  in  the  epigas* 
trium.  On  pressing  the  abdominal  parietes  from  below  upwards,  we  felt  a little 
above  the  umbilicus  a well  defined  edge,  which  appeared  evidently  to  belong  to 
the  liver.  In  every  part  where  this  tumour  was  felt,  pressure  was  a little 
painful.  There  was  no  appetite  ; there  never  had  been  either  vomiting  or 
nausea.  The  alvine  evacuations  were  scanty,  and  consisted  of  hard  black  sub- 
stances. Our  unfavourable  prognosis  was  founded  principally  on  the  long 
standing  of  the  jaundice,  and  on  the  disturbance  of  the  gastric  functions,  and 
principally  on  the  emaciated  state  of  the  patient.  One  would  have  believed, 
and  not  without  some  reason,  that  there  was  organic  lesion  of  the  stomach  and 
liver,  which  had  undergone  considerable  increase  in  size.  M.  Lerminier  on 
the  first  day  ordered  twelve  leeches  to  be  applied  to  the  right  hypochondrium. 
On  the  following  days  emollient  ptisans,  and  some  broths,  were  all  the  nourish- 
ment he  took  ; afterwards  he  took  some  pills,  consisting  of  calomel  and  soap, 
with  some  vegetable  juices,  Vichy  water,  etc.  After  remaining  about  one 
month  in  the  hospital,  the  first  change  observed  was  a modification  in  the  alvine 
evacuations  ; they  were  become  yellow,  of  less  consistence  and  less  scanty ; 
we  then  observed  the  tumefaction  of  the  epigastrium  and  of  the  right  hypochon- 
drium become  less  and  less  perceptible,  the  jaundice  diminished,  the  evening 
febrile  accession  disappeared,  and  the  appetite  returned.  Three  months  after 
his  admission  the  patient  recovered  flesh ; the  jaundice  was  gone.  He  went 
out  perfectly  recovered. 

The  unexpected  recovery  of  this  individual  induces  us  to  think  that  there  was 
not  in  him,  as  in  the  preceding  patient,  anything  more  than  mere  chronic  san- 
guineous congestion  of  the  liver,  or,  if  you  will  have  it,  a chronic  hepatitis  in 
the  first  stage,  without  serious  alteration  of  the  texture  of  the  organ.  Such  cases 
are  sufficiently  uncommon  to  entitle  them  to  the  attention  of  the  practitioner. 
The  disease  seemed  to  have  commenced  with  inflammation  of  the  digestive 
passages,  which,  having  been  attacked  in  its  acute  stage  by  the  application  of 
leeches,  continued  in  the  chronic  form,  and  extended  to  the  biliary  apparatus. 
When  we  saw  the  patient,  the  only  sign  of  gastric  affection  about  him  was  a 
total  loss  of  appetite.  Was  this  symptom  sufficient  to  prove  the  existence  of 
gastritis  ? Be  that  as  it  may,  at  first  leeches  were  applied  over  the  part,  where 
examination  with  the  hand  detected  an  hepatic  engorgement;  and  after  some 
duys  of  mere  antiphlogistic  treatment,  some  calomel  pills  were  given,  some 
vegetable  juices,  and  Vichy  water.  If  there  had  been  gastro-intestinal  inflam- 
mation, must  not  these  means  have  exasperated  it?  and  yet  it  was  during  the 
employment  of  such  treatment  that  we  saw  all  the  bad  symptoms  disappear  by 
degrees,  and  the  health  return  contrary  to  our  expectation.  English  physicians 
will  carefully  note  in  this  fact  the  change  of  the  alvine  evacuations,  which  re-, 
turned  to  a much  more  natural  state  a little  time  after  the  calomel  was  com- 
29* 


312 


ANDIIAL’S  MEDICAL  CLINIC, 


menced  ; they  would  observe  that  it  was  in  consequence  of  this  change  in  the 
nature  of  the  stools,  that  any  amendment  was  seen  to  take  place.  According  to 
some,  such  an  amendment  should  be  accounted  for  by  a revulsion  established 
in  the  digestive  tube ; according  to  others,  by  a specific  action  on  the  liver, 
produced  by  the  medicines  employed  ; according  to  others,  by  one  irritation, 
which,  even  in  the  liver,  succeeded  to  another.  For  our  part  we  shall  confine 
ourselves  to  the  statement  of  the  fact,  and  to  saying  that  the  recovery  took  place 
at  the  same  time  that  medicines  were  administered,  which  should  have  retarded 
it,  according  to  the  principles  of  the  doctrine  of  irritation.  We  shall  remark, 
however,  that  the  very  strict  regimen  under  which  the  patient  was  placed,  and 
the  very  close  observance  of  the  rules  of  hygiene,  might  also  act  an  important 
part  in  the  cure. 

It  will  not,  in  my  opinion,  be  out  of  place  to  subjoin  to* this  case  a fact  ob- 
served in  the  city  in  my  father’s  practice,  and  which  affords  another  instance 
of  recovery  from  an  affection  of  the  liver,  which  had  been  for  a long  time  con- 
sidered as  likely  to  terminate  fatally.  I myself  had  an  opportunity  of  observing 
the  cases  in  different  periods  of  its  existence  ; both  in  the  epigastrium,  as  well 
as  in  the  right  hypochondrium,  I felt  and  detected  the  existence  of  tumours, 
which  have  since  completely  disappeared. 

Madame  the  Marchioness  de  J had  had  for  several  years  almost  constant 

pains  in  the  epigastric  region,  pains  which  increased  after  meals.  When  she  had 
attained  the  critical  period  of  life,  her  digestion  became  still  more  painful  ; the 
appetite  diminished  more  and  more  ; the  skin  assumed  a yellow  tint,  which  was 
soon  changed  to  a real  jaundice  ; the  patient  became  emaciated,  and  some  fever 
set  in,  which  at  first  existed  only  in  the  evening  and  at  night,  and  then  assumed  a 
continued  form.  At  the  same  time  that  these  different  symptoms  appeared,  an 
unusual  resistance  began  to  be  felt  in  the  epigastrium  and  right  hypochondrium. 
In  a short  time  the  existence  of  a tumour  in  these  regions  was  no  longer  a matter 
of  doubt;  its  form  and  situation  seemed  to  indicate  that  this  tumour  appertained 
to  the  liver;  some  inequalities  were  felt  in  it.  Pressure  generally  gave  pain; 
there  was  alternately  constipation  and  purging.  In  about  a year  the  patient  was 
reduced  almost  to  the  last  stage  of  marasmus  ; the  lower  extremities  were  usually 
a little  infiltrated.  Several  physicians,  MM.  Portal  and  Lerminier  among 
others,  thought,  with  my  father  and  me,  that  this  lady  laboured  under  organic 
disease  of  the  liver,  and  the  prognosis  was  of  course  very  unfavourable.  The 
patient  was  now  unable  to  digest  anything.  Mercurial  frictions  were  employed 
over  the  origin  of  the  liver,  without  appearing  to  do  either  good  or  harm.  One 
day,  after  having  taken  some  vegetable  juice,  Madame  de  J.  had  some  vomit- 
ing, and  particularly  very  profuse  diarrhoea.  But  what  was  remarkable,  after 
this  kind  of  indigestion,  as  she  called  it,  she  found  herself  evidently  better.  It 
is  quite  certain  that,  dating  from  this  period  (whether  there  was  a real  con- 
nexion or  mere  coincidence),  the  disease,  which  then  seemed  continually  to  be- 
come more  alarming,  began  to  assume  a less,  unfavourable  aspect.  The  fever 
ceased  to  be  continued  ; the  tumefaction  of  the  hypochondrium  and  of  the  epi- 
gastrium diminished  ; the  inequalities  felt  in  that  region  were  no  longer  percep- 
tible ; the  jaundice  became  less  marked.  The  patient  was  then  put  on  asses’ 
milk  for  nourishment ; this  she  bore  very  well,  and  she  eventually  took  a great 
quantity  of  it  every  day.  By  degrees  her  appetite  returned,  the  digestive  func- 
tions were  restored,  she  began  to  be  able  to  take  solid  food,  her  flesh  returned, 
the  jaundice  disappeared  completely  with  the  tumour  of  the  liver.  This  lady 
is  at  present  in  the  enjoyment  of  good  health  ; her  appetite  and  digestion  are  ex- 
cellent, and  she  is  able  to  perform  long  journeys  on  foot. 

It  is  very  remarkable  that,  in  the  two  cases  of  recovering  from  liver  affection 
now  detailed,  the  improvement  commenced  in  consequence  of  a change  pro- 
duced by  art:  in  the  first  case  the  stools  became  gradually  more  frequent,  more 


DISEASES  OF  THE  ABDOMEN. 


343 


liquid,  more  yellow  ; in  the  second  case  a profuse  diarrhcea  set  in  all  at  once. 
If  this  were  the  proper  place,  we  should  feel  no  reluctance  to  cite  some  cases 
witnessed  by  ourselves,  in  which  we  have  seen  different  morbid  states  improve 
and  recover  after  the  administration  of  the  too  celebrated  purgative  of  Le  Roy , 
which,  in  the  hands  of  ignorant  practitioners,  has  made  so  many  victims. 
The  more  the  present  direction  of  medical  opinion  turns  physicians  from  such 
a system  of  treatment,  the  more  important  is  it  to  inquire  into  its  effects,  and 
to  satisfy  ourselves  whether  here,  as  in  most  human  affairs,  a small  portion  of 
good  may  not  be  found  mixed  up  with  much  that  is  bad. 

Case  5. — Chronic  gastritis — Intermittent  hepatitis  ; indolent  tumour  in  the  right  hypochon- 
drium,  jaundice — Cure  of  the  liver  affection. 

An  individual,  about  sixty-three  years  of  age,  who  had  for  several  years  back 
been  labouring  under  painful  digestion,  habitual  pain  in  the  epigastrium,  fre- 
quent vomiting  of  acrid  matters,  etc.,  met  with  a severe  reverse  in  his  circum- 
stances about  a month  before  entering  the  Charite.  During  the  fifteen  days 
following,  the  pain  in  the  epigastrium  was  more  acute,  frequent  nausea,  total 
loss  of  appetite,  and,  at  the  end  of  these  fifteen  days,  an  appearance  of  jaundice. 
After  the  latter  had  been  in  existence  about  a fortnight,  he  entered  the  Charite. 
All  the  skin  was  then  of  a yellow  colour,  as  also  the  conjunctivae.  On  examin- 
ing the  abdomen  with  the  hand,  the  edge  of  the  liver  was  felt  full  two  fingers’ 
breadth  below  the  cartilaginous  edges  of  the  ribs.  Tongue  natural,  epigastrium 
moderately  sensible,  frequent  eructations  ; the  patient  vomited  from  time  to 
time  a yellow  and  bitter  liquid  in  considerable  quantity,  having  all  the  physi- 
cal characters  of  bile  ; there  was  not  then  any  obliteration  of  the  ductus  chole- 
dochus,  or  of  the  hepatic  duct.  But,  what  is  strange,  at  the  same  time  that  bile 
was  vomited  up  in  great  abundance,  the  stools  were  entirely  devoid  of  colour, 
like  clay.  They  were  also  scanty.  No  fever  at  all.  Twelve  grains  of  calomel 
were  prescribed,  which  procured  no  alvine  evacuation.  For  the  five  days  fol- 
lowing he  remained  in  the  same  state.  Great  itching  in  the  skin.  Urine  of  a 
deep  orange-red  colour  (nitre  whey,  emollient  lavements).  Two  ounces  of 
castor  oil  were  then  prescribed  to  be  taken  in  several  cups  of  vegetable  broth. 
From  five  to  six  stools  were  obtained.  On  the  two  following  days  lavements, 
with  one  ounce  of  sulphate  of  soda  and  half  an  ounce  of  senna  leaves.  (Whey, 
with  a drachm  of  acetate  of  potash.)  Three  or  four  days  after,  recourse  was 
again  had  to  the  castor  oil.  Under  the  influence  of  this  treatment,  the  following 
series  of  phenomena  supervened  ; the  bilious  vomiting  ceased,  according  as  alvine 
evacuations  of  a bilious  character  were  obtained.  The  tumour  in  the  right  hypo- 
chondrium  diminished,  then  disappeared.  The  urine  assumed  a more  natural 
appearance,  the  yellowness  of  the  skin  diminished,  the  pulse  remained  uniformly 
free  from  frequency.  Tilings  being  in  this  state,  M.  Lerminier  prescribed  some 
glasses  of  Vichy  water,  and  pills  consisting  of  calomel  and  soap  (two  grains  of 
each).  Frictions  were  used  over  the  right  hypochondrium,  with  an  ointment 
consisting  of  an  ounce  of  cerate  and  a drachm  of  calomel.  After  remaining 
three  weeks  in  the  Charite  there  was  no  longer  any  trace  of  jaundice ; the  right 
hypochondrium  again  became  soft,  the  vomiting  had  ceased  for  along  time,  and 
the  digestive  functions  were  soon  perfectly  re-established. 

This  case  is  remarkable  with  respect  to  the  succession,  the  order  of  connexion 
of  the  morbid  phenomena,  and  with  respect  to  the  treatment  adopted. 

The  patient  had,  for  along  time  back,  all  the  signs  of  chronic  gastritis,  when, 
in  consequence  of  an  intense  mental  excitement,  this  gastritis  became  worse, 
and  at  a later  period  the  symptoms  of  an  affection  of  the  liver  manifested  them- 
selves. It  is  possible  that  there  was  in  this  case  inflammation  of  the  biliary 
ducts ; but  the  matter  vomited  always  proved  that  these  canals  were  not  obliterated, 


344 


ANDIIAL’S  MEDICAL  CLINIC. 


and  that  the  bile  entered  the  duodenum.  But  what  was  remarkable  is,  that 
whilst  much  bile  was  vomited,  there  was  none  in  the  alvine  evacuations  ; so 
that  one  would  have  said  that,  according  as  it  entered  the  duodenum,  an  anti- 
peristaltic  motion  of  this  intestine  drove  it  towards  the  stomach.  All  we  know 
about  the  liver  affection  is,  that  there  was  jaundice  and  considerable  tumefaction 
of  this  organ.  However,  after  a certain  time,  and  according  as  the  alvine  eva- 
cuations began  to  be  tinged  with  bile,  all  signs  of  the  liver  affection  disappear; 
and  when  the  patient  left  the  hospital,  the  old  symptoms  of  chronic  gastritis 
were  also  very  much  mitigated. 

If  we  now  inquire  under  the  influence  of  what  treatment  the  cure  of  the  dis- 
ease of  the  liver,  and  the  improvement  of  that  of  the  stomach,  appeared  to  be 
produced,  we  shall  find  that  it  all  occurred  during  the  employment  of  purgatives. 
But  we  shall  not  forget  that,  whilst  in  this  particular  case  these  purgatives  had 
a happy  influence  on  the  twofold  disease  of  the  stomach  and  liver,  probably 
by  occasionally  producing  a revulsive  fluxion  on  a lower  part  of  the  digestive 
tube ; under  other  circumstances,  on  the  contrary,  the  employment  of  these 
same  purgatives  has  quite  a contrary  effect,  it  irritates  the  liver  and  produces 
jaundice.  The  question  now  would  be  to  determine  with  precision  the  cases 
where  one  or  other  of  these  effects  takes  place.  We  have  more  than  once  seen 
obstinate  bilious  vomiting  with  constipation,  which  was  accompanied  with  fever, 
resist  the  application  of  leeches  over  the  epigastrium,  and  disappear  at  the  same 
time  that  profuse  alvine  evacuations,  the  result  of  a purgative,  were  established. 
The  fever  also  ceased,  and  the  health  was  soon  restored. 

RECAPITULATION  OF  THE  PRECEDING  OBSERVATIONS. 

The  observations  now  presented  to  the  reader  appear  interesting  for  more 
than  one  reason. 

1st.  With  respect  to  etiology,  they  prove  that  diseases  of  the  liver  may  be 
consecutive  on  gastro-intestinal  inflammation,  but  that  at  other  times  they  are 
primary.  It  is  not  necessary  to  cite  numerous  cases  o‘n  this  point ; one  well 
authenticated  fact  is  sufficient. 

2d.  They  present  instances  of  different  shades  of  acute  or  chronic  hepatitis, 
of  sanguineous  congestions  in  the  liver,  which  may  be  but  temporary,  or  may 
continue  for  a very  long  time,  without  any  serious  alteration  of  nutrition  taking 
place  in  this  organ,  or  without  any  morbid  secretions  arising. 

3d.  Such  affections  of  the  liver  may  terminate  in  death,  either  in  their  acute 
state,  byreacting  sympathetically  on  the  nervous  centres,  or  in  their  chronic  state 
by  the  progressive  wasting  which  they  occasion  ; but,  in  the  great  majority  of 
these  cases,  this  wasting  depends  as  much  on  an  accompanying  affection  of  the 
digestive  tube  as  on  the  disease  of  the  liver. 

4th.  They  may  also  terminate  favourably  by  return  to  health,  either  in  their 
acute,  or  in  their  chronic  state,  after  having  produced  considerable  emaciation  of 
the  patients,  and  after  giving  rise  to  most  of  the  symptoms  which  ordinarily  mark 
the  most  serious  degenerations  of  the  liver. 

5th.  In  their  acute  state  they  may  manifest  their  presence  either  solely 
by  a febrile  disturbance  with  sympathetic  reaction,  more  or  less  marked  on 
different  organs,  without  there  being  either  a tumour  in  the  hypochondrium,  or 
jaundice,  or  pain  ; or  by  these  latter  symptoms  which  may  exist  separate  or 
combined. 

In  their  chronic  state  these  sanguineous  congestions,  or  attacks  of  hepatitis, 
may  simulate  by  their  symptoms,  as  has  been  just  said  (Coroll.  4),  the  different 
changes  of  texture  to  be  mentioned  in  the  following  paragraphs  : — 

6th.  They  may  either  be  continued  or  present  themselves  only  in  an  inter- 
mittent form. 


DISEASES  OF  TIIE  ABDOMEN. 


345 

7th.  The  jaundice,  which  often  accompanies  them,  is  not  always  accompanied 
with  an  obstruction  of  the  bile  ducts. 

8th.  We  have  seen  two  kinds  of  treatment  succeed  in  these  diseases  ; a, 
the  antiphlogistic  treatment ; b , the  treatment  by  purgatives. 

9th.  This  latter  species  of  treatment  has  given  rise  to  results  so  remarkable,  that 
physicians  even  endeavour  to  obtain  them,  by  devoting  themselves  to  the  same 
researches  as  we  have  done. 

10th.  There  are  other  cases  where  the  treatment  by  purgatives  has  been  evi- 
dently injurious. 

llth.  It  still  remains  to  determine  more  accurately  than  we  have  ourselves 
done,  what  are  the  cases  where  one  or  other  of  these  modes  of  treatment  may 
be  employed  with  most  advantage.  Can  the  cases  wherein  the  method  by 
evacuation  has  proved  efficacious  be  all  explained  by  the  principle  of  revul- 
sion ? We  doubt  it. 


ARTICLE  II. 

CASES  RELATING  TO  THE  ALTERATIONS  OF  NUTRITION  OF  THE  PAREN- 
CHYMA OF  THE  LIVER. 

In  the  preceding  cases  we  have  seen  no  other  change  in  the  liver  except  an 
unusual  accumulation  of  blood  within  its  substance.  Observation  has  showed 
us  that  this  active  sanguineous  congestion,  this  first  degree  of  inflammation, 
may  continue  for  an  indefinite  period  in  the  liver,  without  this  latter  organ 
becoming  more  seriously  altered.  But  at  other  times,  whether  consecutively 
on  this  same  sanguineous  congestion,  or  simultaneously  with  it,  or  without  its 
being  possible  to  demonstrate  otherwise  than  by  analogy  that  it  ever  existed, 
the  nutrition  of  the  liver  deviates  from  its  normal  slate  ; whence  there  may 
result,  1st,  different  modifications  in  its  form,  size,  colour,  and  consistence; 
2d,  changes  more  or  less  appreciable  in  its  circulation,  and,  in  consequence, 
divers  local  or  general  symptoms,  depending  on  the  different  species  of  changes 
which  the  organ  has  undergone. 


SECTION  I. 

OBSERVATIONS  ON  HYPERTROPHY  OF  THE  LIVER. 

Case  6. — General  hypertrophy  of  the  liver — Chronic  gastro-duodenitis — No  jaundice. 

A printing  compositor,  forty-three  years  of  age,  entered  the  Charite  in  the 
following'  state  : great  emaciation,  face  pale  ; copper-coloured  spots  on  the  skin 
of  the  chest,  back,  and  extremities.  Sharp  edge  of  the  liver  very  distinctly  felt 
a little  below  the  umbilicus,  and  capable  of  being  traced  towards  the  left  side, 
to  the  extent  of  two  or  three  fingers’  breadth  beyond  this  point.  In  all  the 
space  included  between  two  lines  supposed  drawn  the  one  from  the  middle  of 
the  cartilaginous  edge  of  the  left  false  ribs  to  as  far  as  a little  below  the  umbilicus, 
and  the  other  from  this  last  point  as  far  as  the  right  flank,  there  is  felt  a hard 
body,  with  smooth  surface,  which  terminates  inferiorly  at  the  sharp  edge  now 
mentioned,  the  limits  of  which  on  the  left  cannot  be  accurately  defined,  and 
which  superiorly  seems  to  be  continued  behind  the  ribs.  We  had  no  doubt 
but  this  body  was  the  liver  enlarged.  The  tumour  which  it  formed  was  com- 
pletely indolent.  But  when  the  patient  ate,  or  drank  wine,  he  experienced  a 
painful  sensation  in  the  epigastrium,  which  sometimes  was  but  momentary,  and 
sometimes  continued  for  several  hours.  The  tongue  retained  its  natural  appear- 
ance ; or,  if  it  deviated  from  it,  it  was  only  in  becoming  paler.  There  was 


34G 


ANDIIAL’S  MEDICAL  CLINIC. 


habitual  anorexia,  without  any  increase  of  thirst,  without  nausea  or  vomiting. 
The  stools  were  scanty,  consisting  of  hard  and  brown  matter  : urine  small  in 
quantity,  red,  and  depositing  a sediment.  The  pulse  was  habitually  frequent, 
without  the  skin  being  hot.  The  patient  stated,  that  six  years  before  entering 
the  hospital  he  took  a great  quantity  of  Van  Swieten’s  liquor  and  of  the  decoc- 
tion of  sarsaparilla,  and  that  these  remedies  not  freeing  him  from  large  indolent 
buboes  which  appeared  in  the  groin  after  chancres  on  the  penis,  he  took,  by 
the  advice  of  an  individual  who  judged  of  his  case  by  the  appearance  of  his 
urine,  a certain  quantity  of  sulphuric  acid  combined  with  cream  of  tartar.  But 
after  employing  this  remedy  for  several  days,  he  was  seized  on  a sudden  with 
an  acute  tearing  pain  in  the  epigastrium,  the  appearance  of  which  was  accom- 
panied with  a temporary  loss  of  consciousness,  and  convulsions  resembling  those 
of  epilepsy.  During  the  fifteen  days  following,  he  kept  his  bed  ; the  epigastric 
pain  assumed  gradually  its  original  severity ; but  from  this  period  digestion  re- 
mained painful,  the  appetite  was  lost,  the  patient’s  strength  and  flesh  gradually 
diminished.  The  patient  was  not  aware  of  the  existence  of  the  tumour  formed 
by  the  liver,  which  is  not  to  be  wondered  at,  since  it  did  not  project  through  the 
abdominal  parieties,  and  it  was  not  painful. 

This  person  lived  for  nearly  six  weeks  in  the  Charite  : during  this  time  we  saw 
him  pine  away,  and  grow  weaker  and  weaker.  He  never  had  fever,  properly 
speaking.  During  the  last  ten  days  of  his  life,  he  vomited  four  different  times, 
and  in  large  quantity  every  time,  a black  matter  resembling  coffee-grounds  ; from 
that  time,  his  features  went  on  changing  more,  the  extremities  became  cold. 
Coma  set  in,  and  he  died. 

Post-mortem . The  abdominal  parietes  being  removed,  the  first  object  which 
struck  us  was  the  enormous  size  which  the  liver  had  attained.  It  covered  a 
great  portion  of  the  intestines,  extended  inferiorly  to  a little  above  the  crest  of 
the  ileum,  and  passed  considerably  beyond  the  linea  alba.  With  respect  to  size, 
it  bore  somewhat  the  same  relation  to  the  other  organs  that  it  does  in  the  foetus. 
Its  external  surface  presented  the  two  natural  substances  of  the  liver  in  a very 
marked  manner.  The  same  was  observed  internally.  There  was  nothing  ab- 
normal in  the  texture  of  the  organ.  It  was  neither  harder  nor  softer  than 
usual ; on  making  an  incision,  only  a small  quantity  of  blood  flowed  from  it. 
The  gall-bladder  did  not  contain  more  bile  than  usual ; this  bile  was  of  a clear 
yellow  colour. 

The  stomach,  which  was  small  and  contracted,  was  concealed  by  the  liver. 
Its  parietes  were  hard  to  the  touch.  Its  external  surface  was  of  a slate  colour 
throughout  its  entire  extent,  and  was  as  it  were  mammillated.  The  latter  ap- 
pearance depended  on  considerable  hypertrophy  of  the  mucous  membrane. 
This  hypertrophy  was  unequal  in  intensity  in  different  points  of  the  stomach  ; 
where  it  was  very  marked,  its  existence  was  indicated  by  a sort  of  elevations, 
and  between  them  were  depressions  where  the  mucous  membrane  was  rather 
attenuated.  The  submucous  cellular  tissue  participated  a little,  particularly 
towards  the  pylorus,  in  the  thickening  of  the  membrane  which  covered  it.  The 
duodenum  presented  on  its  internal  surface  the  same  slate-coloured  tint  as  we 
had  already  found  in  the  stomach.  The  suprarenal  capsules  appeared  very 
much  enlarged.  A great  quantity  of  black  colouring  matter  was  deposited  in 
the  cellular  tissue  of  the  lungs,  both  the  interlobular  and  intervesicular  ; there 
was  a great  quantity  of  it  also  in  the  bronchial  glands. 

This  case  presents  to  us  an  instance  of  disease  of  the  liver  which  consists 
solely  in  a more  active  nutrition  of  this  organ,  similar  to  that  of  which  the  heart 
is  sometimes  the  seat.  There  was  an  increase  in  the  number  of  its  molecules, 
without  their  density,  texture,  anatomical  or  chemical  composition  being  at  all 
modified.  Can  we  say  that  the  production  of  such  a state  was  preceded  by 
inflammation,  or  simply  of  a more  copious  and  active  afflux  of  blood  than 


diseases  of  the  abdomen. 


347 


that  of  which  the  liver  is  ordinarily  the  seat?  Might  it  not  be  as  well  sup- 
posed that  the  same  quantity  of  blood  as  usual  coming  to  the  liver,  there  was 
separated  from  it  by  a more  active  elaboration,  a greater  quantity  of  nutritive 
materials  ? 

Of  the  different  symptoms  presented  by  the  patient,  none  seemed  to  be  con- 
nected with  the  affection  of  the  liver.  There  was  neither  jaundice  nor  dropsy  ; 
there  was  in  fact  no  reason  for  the  occurrence  of  the  latter  disease,  as  the  liver 
was  not,  properly  speaking,  engorged,  nor  were  its  vessels  obstructed.  The 
bad  symptoms,  the  emaciation,  and  death  appear  principally  to  have  been  owing 
to  the  gastric  duodenitis.  The  cause,  under  the  influence  of  which  this  occurred, 
is  evident.  Having  appeared  at  first  in  an  acute  form  after  the  introduction  of 
a certain  quantity  of  sulphuric  acid  into  the  stomach,  it  continued  in  a chronic 
form  for  six  years,  at  the  end  of  which  time,  the  constantly  increasing  abolition 
of  the  digestive  functions  produced  wasting  and  death.  It  is  possible  that  the 
hypertrophy  of  the  liver  was  consecutive  on  the  gastro-duodenal  inflammation, 
and  this  circumstance  might  induce  one  to  think  that  the  hypertrophy  was  the 
result  of  an  inflammatory  process. 

One  might  suppose,  ci  priori, that  in  a case  where  the  nutrition  of  the  liver 
had  taken  on  so  extraordinary  an  increase,  the  secretion  of  bile  should  also  be- 
come proportionally  increased.  However,  this  was  not  the  case:  during  life 
but  little  bile  had  been  discharged,  and  after  death  the  gall-bladder  contained 
but  a small  quantity  of  it;  even  that  contained  in  it  seemed  to  consist  of  more 
water  and  albumen  than  usual,  as  if  at  the  same  time  that  the  nutrition  of  the 
liver  became  more  active,  its  secreting  power  diminished.  The  following  case 
will  serve  probably  to  confirm  this  conjecture  : it  will  furnish  an  instance  of 
jaundice  without  any  other  alteration  of  the  liver  than  simple  hypertrophy. 

Case  7. — General  hypertrophy  of  the  liver,  with  jaundice — Diarrhoea  for  some  time  before 

death,  withoutjany  appreciable  alteration  of  the  intestine — Attenuation  of  the  parietes  of 

the  stomach. 

A gardener,  thirty-three  years  of  age,  presented  a greenish  yellow  tinge  over 
all  the  skin,  when  he  entered  the  Charite.  He  told  us  that  he  had  had  jaun- 
dice for  about  the  last  three  years  ; that  it  came  on  without  his  being  able  to 
assign  any  cause  for  it ; that  before  the  appearance  of  this  jaundice,  he  had 
always  enjoyed  good  health,  and  that  during  the  first  year  he  had  not  even  felt 
ill;  but  that  gradually  during  the  two  following  years  his  strength  had  dimi- 
nished, and  a state  of  considerable  emaciation  had  succeeded  to  his  habitual 
embonpoint ; he  had  lost  appetite,  and,  without  ever  experiencing  any  real  pain 
in  the  epigastrium,  he  felt  a sense  of  weight  and  fulness  in  this  region  after 
eating  ; he  had  from  time  to  time  some  diarrhoea.  When  this  patient  came 
under  our  observation,  we  detected  in  the  abdomen  a tumour  precisely  similar 
to  that  described  in  the  sixth  case.  It  had  the  same  form  and  the  same  extent ; 
like  that  it  was  not  painful ; the  tongue  was  natural,  the  mouth  was  free  from 
any  bitter  taste,  stools  scanty,  of  moderate  consistence,  and  white.  Pulse  not 
frequent.  We  saw  this  patient  continually  waste  away  ; towards  the  termina- 
tion of  life  serous  and  profuse  diarrhoea  set  in  and  accelerated  death.  The 
patient  had  been  treated  merely  with  demulcents. 

Post-mortem.  The  liver,  which  was  of  an  enormous  size,  touched  inferiorly 
the  crest  of  the  right  ileum  ; and  on  the  left  it  extended  as  far  as  the  flank.  In 
other  respects  its  texture  did  not  appear  in  any  way  altered  ; and  on  making 
an  incision,  or  by  pressure,  only  a small  quantity  of  blood  was  made  to  flow 
from  it.  The  gall-bladder  contained  nothing  but  a serous  liquid,  very  slightly 
tinged  of  a yellow  colour.  The  bile  ducts  were  empty,  and  their  mucous  mem- 
brane of  a greyish  colour,  without  appearing  to  be  at  all  changed  in  texture. 

The  internal  texture  of  the  stomach  was  pale,  even  over  all  its  splenic  portion  ; 


34S 


ANDRAL’S  MEDICAL  CLINIC. 


its  parietes  were  so  attenuated  as  to  be  transparent : in  vain  did  we  seek  for 
some  traces  of  the  muscular  tunic ; the  mucous  membrane  itself  was  no  longer 
apparent:  all  that  was  seen  there  was  a cellular  web,  smooth  and  polished  ex- 
ternally, to  form  the  peritoneum.  We  found  no  other  appreciable  alteration  in 
the  digestive  tube. 

This  case  resembles  the  preceding  both  with  respect  to  the  alteration  of  the 
liver,  and  the  absence  either  of  pain  or  dropsy.  But  in  the  subject  of  the  sixth 
case  there  was  no  jaundice.  Only  the  elements  of  the  bile  contained  in  the 
gall-bladder  seemed  to  be  less  in  quantity  than  usual.  Here  there  was  a well- 
marked  jaundice,  and  there  was  nothing  to  prove  that  in  this  hypertrophied 
liver  the  bile  was  still  secreted,  or  if  it  was,  it  was  but  in  very  small  quantity. 
In  fact  the  gall-bladder  contained  instead  of  bile  nothing  but  a little  serum  with 
a slightly  yellow  tinge  ; the  bile  ducts  were  devoid  of  colour,  as  if  no  bile  passed 
through  them  for  a long  time  ; and  during  life  the  alvine  evacuations  did  not 
appear  to  contain  any.  It  appeared,  then,  that  according  as  the  nutrition  of 
the  liver  became  unusually  active,  its  power  of  secretion  became  more  and 
more  diminished,  and  it  at  length  was  entirely  abolished.  The  materials  of 
the  bile  no  longer  finding  a passage  through  this  natural  emunctory,  and  being 
but  imperfectly  eliminated  by  the  kidneys,  partly  remained  in  the  blood,  and 
the  colouring  matter  of  the  bile  impregnated  many  of  the  tissues,  or  was  de- 
posited in  them;  thence  the  production  of  jaundice. 

But  what  was  the  cause  of  the  progressive  wasting  of  the  patient?  Must  we 
admit  that  the  unusual  and  long  continued  presence  of  the  materials  of  the  bile 
in  the  blood  produced  an  injurious  influence  on  the  nutrition  and  vital  properties 
of  the  different  parts  to  which  it  was  distributed  ? Was  it  the  active  process  of 
nutrition  going  on  in  the  liver,  which,  concentrating  an  inordinate  degree  of  force 
in  this  organ,  prevented  the  other  parts  from  being  able  properly  to  repair  their 
losses  ? No  doubt  one  or  other  of  these  causes  may  contribute  to  the  wasting  of 
the  patient ; but  what  must  not  be  forgotten  as  a cause  of  this  wasting,  is  the 
state  of  the  stomach.  Atrophied  as  it  was  over  a considerable  portion  of  its 
extent,  could  it  still  duly  perform  the  function  of  chymefaction  ? Thus,  during 
life,  there  was  loss  of  appetite,  and  epigastric  weight  after  the  taking  of  food. 
But  was  this  atrophy,  this  attenuation  of  the  gastric  parietes,  the  result  of  a 
previous  inflammation  or  irritation  ? There  is  nothing  to  prove  it. 

With  respect  to  the  diarrhoea  which  existed  towards  the  termination  of  life, 
we  found  no  appreciable  alteration  in  the  intestine  to  account  for  it.  Those 
who  will  have  it  that  wherever  there  is  an  increase  in  the  habitual  secretion, 
there  has  been  previous  increase  in  the  afflux  of  blood,  or  a process  of  irritation, 
will  also  admit  it  in  this  case,  though  pathological  anatomy  detects  no  trace  of 
it.  It  would  then  be  necessary  to  commence  to  show  that  every  time  a liquid 
is  separated  from  the  blood  in  a greater  quantity  than  usual,  there  has  been  vital 
exaltation,  irritation,  or  inflammation  in  the  part  where  this  separation  takes 
place.  But  this  is  in  many  cases  a mere  hypothesis,  for  which  many  others 
might  equally  well  be  substituted.  Still  further,  there  are  facts  which  directly 
combat  this  hypothesis.  Is  there  irritation  in  the  cold  pallid  skin  of  an  indi- 
vidual who  is  about  to  die,  or  who  falls  into  a faint  ? Oftentimes,  however,  this 
icy-cold,  bloodless  skin,  is  covered  with  a profuse  sweat. 


SECTION  II. 

SOFTENING  OF  THE  LIVER. 

Case  8. — Red  softening  of  the  liver — Continued  fever  with  pain  in  the  right  hypochondrium — 
Very  slight  icteric  tint,  urine  yellow— Complication  of  acute  peritonitis. 

A man,  thirty-nine  years  of  age,  was  in  the  enjoyment  of  good  health,  when 


DISEASES  OF  THE  ABDOMEN. 


349 


on  the  17th  of  October  he  felt  an  acute  pain  over  all  the  inferior  tmd  lateral  part 
of  the  right  side  of  the  chest  under  the  false  ribs.  The  preceding  night  he  had 
not  slept,  and  had  felt  some  shivering.  For  the  three  following  days  this  pain 
continued  ; there  was  fever.  On  the  20th  of  October  we  found  the  patient  in 
the  following  state : the  cheeks  (pommettes ) were  of  a bright  red  colour,  the 
rest  of  the  face  pale  ; the  conjunctive  were  of  a natural  colour;  the  patient  felt 
in  the  lower  and  right  side  of  the  chest,  from  the  seventh  to  about  the  eleventh 
rib,  a continued  intense  pain,  which  was  increased  neither  by  pressure  nor  by 
percussion.  It  became  more  acute  by  lying  on  the  left  side.  The  right  hypo- 
chondrium  had  retained  its  soft  feel,  and  might  be  pressed  without  pain  ; the 
breathing  was  free;  there  was  no  cough;  the  respiratory  murmur  was  heard 
in  every  part  distinct  and  not  too  loud  ; the  tongue  was  whitish,  not  much  thirst, 
epigastrium  not  painful,  nor  the  rest  of  the  abdomen.  There  had  been  no  stool 
since  the  commencement  of  the  disease ; the  pulse  was  strong  and  frequent ; 
the  skin  hot,  and  covered  with  a profuse  sweat,  which  tinged  the  linen  of  a 
yellow  colour  ; the  urine,  which  was  in  the  ordinary  quantity,  presented  a 
yellow  colour  of  well-marked  bile. 

What  was  the  nature  of  this  affection?  was*  it  a pleuritis  ? but  there  would 
have  been  some  cough,  and  more  especially  the  pain  would  have  been  increased 
by  the  inspiratory  movements.  One  circumstance  struck  us,  namely,  the 
yellow  colour  of  the  urine,  as  well  as  the  deposition  of  the  same  colour  which 
the  sweat  left  on  the  linen.  Did  not  this  indicate  a disturbance  in  the  biliary 
secretion  ? and  might  we  not  from  this  presume  that  the  pain  above  described 
was  connected  with  the  liver,  or  at  least  with  its  fibro-serous  envelope  ? thence 
the  febrile  disturbance,  which  was  not  accounted  for  by  any  apparent  lesion  of 
the  digestive  tube.  M.  Lerminier  prescribed  a bleeding  of  sixteen  ounces, 
twenty  leeches  to  the  anus,  linseed  ptisan,  and  emollient  lavements.  During 
the  three  days  following  the  different  symptoms  now  described  continued;  the 
conjunctive  al^o  assumed  a slight  yellow  tint,  as  well  as  the  skin  of  the  face 
and  of  the  anterior  part  of  the  chest.  Only  one  evacuation  was  obtained  by 
each  lavement.  He  coughed  a little,  and  the  expectoration  was  that  of  simple 
catarrh  (emollient  ptisans,  strict  diet). 

The  disease  was  now  come  to  the  eighth  day.,  nor  was  there  as  yet  any  ap- 
pearance of  its  resolution,  neither  did  any  thing  of  a decidedly  alarming  charac- 
ter as  yet  present  itself,  when  all  at  once  the  pain  of  the  lower  part  of  the  chest 
on  the  right  side  became  very  severe,  and  extended  to  the  right  hypochondrium. 
On  the  tenth  day  the  latter  was  very  sensible  on  the  least  pressure  ; twelve 
leeches  were  applied  to  it.  In  the  course  of  the  day  the  pain  extended  to  the 
entire  abdomen.  It  was  everywhere  increased  by  pressure.  At  the  same  time 
the  skin  which  remained  constantly  moist,  became  dry  ; the  pulse  became  small 
and  wiry,  and  much  more  frequent  ; the  features  were  strikingly  altered  (thirty 
leeches  over  the  abdomen).  From  the  eleventh  to  the  thirteenth  day  the  abdo- 
minal pains  continued,  the  cause  of  which  evidently  lay  in  an  inflammation  of 
the  peritoneum  ; tension  of  the  abdomen;  some  vomiting;  constipation  ; pulse 
thready  ; gradual  coldness  of  the  cutaneous  surface.  He  died  on  the  fourteenth 
day  of  the  primary  disease,  and  on  the  seventh  of  the  peritonitis. 

Post-mortem. — Effusion  of  a small  quantity  of  purulent  liquid  into  the  peri- 
toneum, principally  in  both  flanks.  The  convolutions  of  the  intestines  were 
held  together  slightly  by  soft  pseudo-membranes  of  recent  formation.  The  entire 
liver  was  as  it  were  enveloped  by  a thick  purulent  stratum,  extended  into  the 
form  of  membrane.  On  drawing  this  organ  slightly  out  of  its  place,  we  were 
astonished  at  tearing  it.  Its  tissue  was  extremely  friable.  It  was  reduced  into 
a reddish  pulp  by  the  least  pressure.  The  tissue  of  the  liver  thus  softened  re- 
sembled the  tissue  of  certain  softened  spleens.  It  was  of  a uniformly  red  colour, 
30 


350 


ANDRAL’S  MEDICAL  CLINIC. 


and  presented  no  other  alteration  of  texture.  Its  size  was  not  perceptibly  in~ 
creased. 

We  here  find  a more  serious  alteration  than  in  the  preceding  cases.  There 
is  no  longer  merely  an  unusual  accumulation  of  blood,  or  a more  active  nutrition 
of  the  organ;  its  consistence  is  modified,  and  through  its  entire  extent  slight 
pressure  reduced  it  to  a sort  of  reddish  pulp.  If  we  inquire  when  this  remark- 
able softening  of  the  liver  commenced,  we  shall  consider  it  as  very  probable 
that  it  was  an  acute  affection,  and  one  which  was  the  result  of  a real  hepatitis, 
the  first  symptoms  of  which  appeared  on  the  17th  of  October.  We  see  how 
slightly  marked  these  symptoms  were.  The  hypochondrium  was  free  from 
pain,  and  not  swollen  ; there  was  merely  pain  on  a line  with  the  last  ribs  on 
the  right  side.  But  of  how  many  different  affections  might  not  this  pain  be 
the  sign  ! we  have  seen  in  the  course  of  the  case  how  the  state  of  the  urine 
and  of  the  sweats  contributed  to  throw  light  on  the  real  nature  of  the  disease, 
and  how,  at  a later  period,  the  slight  icteric  tint  of  the  skin  and  conjunctivae 
came  to  confirm  the  diagnosis. 

There  is  nothing  to  prove  that  in  this  case  the  point  of  departure  of  the  hepa- 
titis was  a gastro-intestinal  inflammation.  But  one  might  ask  whether  the  pain 
depended  on  an  inflammation  of  the  parenchyma  of  the  liver,  or  whether  it  was 
not  rather  the  result  of  an  inflammation  developed  in  the  portion  of  the  perito- 
neum which  surrounds  the  liver. 

Case  9. — Softening  of  the  liver  with  loss  of  colour  of  its  tissue — Serum  instead  of  bile  in  the 

gall-bladder  ; bilious  yellow  colour  of  the  urine  and  sweat,  without  jaundice,  whitish  stools — 

Symptoms  of  chronic  gastritis  with  healthy  state  of  the  stomach. 

A shoemaker,  about  fifty-eight  years  of  age,  commenced  to  lose  flesh,  and 
strength,  and  to  suffer  from  indigestion  about  two  years  before  entering  the 
Charite.  He  never  had  any  pain  in  the  epigastrium,  nor  in  any  part  of  the 
abdomen  ; never  any  nausea  or  vomiting  ; but  there  was  loss  of  appetite,  at 
first  exisitng  only  at  intervals,  and  then  becoming  constant,  a feeling  of  indis- 
position, and  of  weight  towards  the  lower  part  of  the  epigastrium  to  the  right 
side,  five  or  six  hours  after  taking  food.  Only  one  month  before  entering  the 
Charite  the  patient  kept  his  bed  ; from  the  onset  of  his  illness,  and  during  its 
progress,  leeches  had  been  applied  several  times  to  the  epigastrium,  without 
any  relief  being  experienced  from  them.  This  group  of  symptoms  seemed  to 
indicate  a chronic  affection  of  the  stomach ; the  following  are  the  additional 
symptoms  which  we  observed: — nothing  remarkable  in  the  tongue  except  its 
extreme  paleness;  no  bad  taste  in  the  mouth.  The  epigastrium  was  soft,  free 
from  pain  as  well  as  the  rest  of  the  abdomen ; the  patient  for  a long  time 
back  took  nothing  but  milk  for  nourishment,  and  he  found  it  agree  with  him 
very  well.  The  stools  were  scanty,  and  of  a very  remarkable  appearance  ; they 
were  whitish,  totally  devoid  of  colour,  as  in  jaundiced  patients,  still  neither 
the  skin  nor  conjunctivae  presented  any  trace  of  jaundice.  But  the  urine  which 
was  voided  in  considerable  quantity,  was  of  a very  remarkable  orange  colour, 
such  as  is  observed  in  jaundice  ; in  a word,  the  patient  sweated  often  from  the 
head,  and  the  linen  which  came  in  contact  with  this  sweat  was  coloured  yellow. 
The  pulse  was  ordinarily  a little  frequent,  without  the  skin  being  hot.  The 
emaciation  was  considerable.  We  considered  this  patient  as  labouring  under 
chronic  gastritis,  and  further,  from  the  nature  of  the  stools,  the  urine,  and  the 
sweat,  we  thought  that  the  affection  of  the  stomach  was  complicated  with  some 
lesion  of  the  liver. 

During  the  two  months  the  patient  remained  in  the  Charite — at  the  end  ot 
which  time  he  died  without  a struggle,  in  a state  of  great  exhaustion — the 
symptoms  which  he  presented  on  his  admission  did  not  change,  and  we  merely 


DISEASES  OF  THE  ABDOMEN. 


351 


observed  him  to  become  emaciated  and  continually  more  feeble.  The  milk 
which  he  took  at  first  willingly  enough,  soon  became  disagreeable  to  him ; he 
had  the  most  complete  distaste  for  all  sorts  of  food.  He  asked  for  wine  so  eagerly 
that  it  was  given  to  him,  nor  did  this  liquid  render  the  gastric  symptoms  worse. 
Such  is  not  the  usual  case  of  persons  labouring  under  chronic  inflammation  of 
the  stomach — a disease,  however,  which  did  not  exist  here,  as  we  shall  see. 
The  treatment  consisted  in  the  application  of  a blister  to  the  epigastrium,  and 
simple  emollients  internally. 

Post-mortem.  The  inner  surface  of  the  stomach  was  in  general  white,  exicept 
in  some  points  where,  in  the  submucus  cellular  tissue,  veins  of  considerable  size 
were  seen  to  pass  ; but  in  the  mucous  membrane  itself  no  vessel  was  injected. 
This  membrane  was  every  where  of  its  natural  thickness  and  consistence. 
Neither  did  we  find  any  appreciable  lesion  in  the  duodenum,  nor  in  the  rest  of 
the  digestive  tube.  The  liver  was  then  examined  ; when  viewed  externally  it 
presented  a pale  colour.  When  drawn  gently  out  of  its  place  it  was  torn  ; and 
on  pressing  it  with  the  finger  it  was  found  to  become  reduced  into  a sort  of 
greyish  pap.  In  all  its  points  it  presented  the  colour  of  dead  leaf,  and  whether 
by  incision  or  by  pressure  we  could  scarcely  force  a few  drops  of  blood  from  it. 
It  did  not  grease  the  scalpel,  and  had  an  appearance  altogether  different  from 
that  of  fat  livers.  In  the  gall-bladder  nothing  was  found  in  the  place  of  bile, 
but  a colourless  serous  liquid,  which  on  being  tasted  did  not  appear  to  be  bitter. 
Nothing  remarkable  in  the  bile  ducts,  which  were  all  empty  of  bile. 

This  case  appears  remarkable  in  more  respects  than  one.  It  presents  an 
instance  of  a long-standing  disturbance  of  the  digestive  functions  without  any 
appreciable  change  in  the  structure  of  the  stomach,  duodenum,  or  the  rest  of  the 
intestinal  tube.  In  many  other  individuals,  where  there  had  been  no  other 
symptoms,  we  found,  however,  in  the  stomach  the  most  serious  organic  changes. 
Was  there  then  in  this  case  mere  alteration  of  the  functions  of  the  stomach,  with- 
out lesion  of  its  texture.  We  think  that  we  must  seek  elsewhere  the  cause  of 
the  disturbance  of  the  digestion,  and  consequently  of  the  progressive  emaciation, 
debility,  etc.  Was  not  this  cause  the  want  of  any  bile  flowing  into  the  duode- 
num ? is  it  with  impunity  that  the  chyme,  which  comes  into  this  intestine  in 
order  to  be  changed  into  a nutritive  juice,  is  now  no  longer  mixed  with  bile  ? 
can  healthy  or  real  chyle  be  then  formed  ? certainly,  in  the  present  state  of 
science,  such  questions  may  be  at  least  raised.  Thence  the  feeling  of  weight 
experienced  by  the  patient  five  or  six  hours  after  having  taken  some  food,  that 
is,  nearly  about  the  time  when  the  latter  should  pass  the  pylorus.  Thence  the 
loss  of  appetite  which  here  was  not  connected  either  with  a state  of  irrita- 
tion or  of  debility  of  the  stomach,  but  which  depended  on  the  general  bad  state 
of  the  nutritive  functions  ; appetite  was  gone,  because  nutrition  itself  evinced  a 
tendency  to  go ; the  chyle  no  longer  forming,  there  was  no  longer  any  chyme- 
faction,  a striking  instance  among  many  others  of  the  close  connexions  by  which 
all  the  vital  acts  are  united  and  correspond. 

If  we  now  inquire  what  was  the  cause  which  prevented  the  bile  from  entering 
the  duodenum,  we  shall  find  that  it  ceased  to  enter  it  (as  the  appearance  of  the 
faeces  sufficiently  proved  during  life)  not  because  an  obstacle  in  the  biliary  pas- 
sages prevented  its  free  excretion,  but  because  the  liver  really  no  longer  formed 
any.  Accordingly  none  was  found  in  the  vessels  scattered  through  the  interior 
of  this  organ,  and  in  the  gall-bladder  nothing  could  resemble  bile  less  than  the 
liquid  contained  in  it.  Thus,  then,  there  seemed  to  have  been  in  this  case  an 
absence  of  the  biliary  secretion.  The  yellow  matter  of  the  bile  was  separated 
from  the  blood  by  other  excietory  passages,  by  the  kidneys,  and  by  the  ex- 
halants  of  the  cutaneous  surface.  But  was  the  blood  duly  depurated  in  this 
way,  and  was  not  this  a new  cause  of  an  alteration  in  the  functions  of  nutrition  ? 

We  shall  consider  it  then  as  a fact  demonstrated  by  experience,  that  in  the 


352 


ANDRAL’S  MEDICAL  CLINIC. 


cases  of  softening  of  the  liver,  similar  to  that  described  in  this  instance,  the 
secretion  of  the  bile  may  be  suspended,  or  at  least  very  much  diminished. 

With  respect  to  the  cause  and  nature  of  this  softening,  was  it  a result  of  chro- 
nic inflammation?  this  maybe  maintained,  but  cannot  be  strictly  demonstrated, 
and  for  our  part  we  are  ready  to  own  that  we  entertain  some  doubts  on  the 
matter. 


ON  INDURATION  OF  THE  LIVER. 

Case  10. — Red  induration  of  the  liver — Ascites — No  other  symptoms  indicating  an  affection 

of  the  liver. 

A lapidary,  thirty-three  years  of  age,  had  always  enjoyed  tolerably  good 
health,  till  the  May  of  1821.  At  this  period,  and  without  having  previously 
caught  cold,  he  had  a profuse  hemoptysis,  which  lasted  for  ten  days  ; he  con- 
tinued to  cough  till  the  end  of  June.  At  this  time  the  symptoms  referable  to 
the  chest  ceased,  the  cough  and  slight  dyspnoea  which  accompanied  it  disap- 
peared ; but  other  symptoms  appeared  on  the  part  of  the  abdomen.  A pain, 
not  severe  but  habitual,  was  felt  towards  the  right  hypochondrium  ; (the  patient 
could  not  describe  its  situation  more  precisely  ;)  the  food  was  several  times 
vomited  ; slight  purging  came  on,  and  now  ceased  only  at  intervals  ; however, 
he  did  not  keep  his  bed,  and  continued  his  usual  business.  During  the  three 
following  months,  these  symptoms  still  went  on,  his  flesh  and  strength  pro- 
gressively diminished.  We  could  not  ascertain  whether  the  pain  of  the  hypo- 
chondrium had  preceded  or  followed  the  first  appearance  of  the  vomiting  and 
diarrhoea.  During  the  months  of  October  and  November,  at  the  same  time  that 
the  face  and  extremities  became  more  and  more  emaciated,  the  abdomen  swelled, 
and  ascites  soon  became  manifest.  He  entered  the  Charite  towards  the  com- 
mencement of  December,  and  presented  the  following  state  : — 

Countenance  pale,  expressive  of  great  suffering,  great  debility,  considerable 
emaciation  of  the  extremities.  Abdomen  very  much  distended  by  a liquid  which, 
when  percussion  is  employed,  evinces  evident  fluctuation  ; there  is  no  pain  in 
any  part;  some  purging  (five  or  six  liquid  stools  in  twenty-four  hours).  Ap- 
pearance of  the  tongue  natural.  Appetite  still  preserved  ; no  fever  ; skin  very 
dry;  respiration  free  ; auscultation  and  percussion  indicate  no  morbid  state  of 
the  thoracic  organs. 

What  was  the  cause  of  the  ascites  in  this  case  ? No  organic  lesion,  as  far  as 
we  could  ascertain,  could  explain  it.  All  that  we  could  learn  was  the  existence 
of  chronic  inflammation  of  the  lower  part  of  the  digestive  tube. 

On  the  day  after  the  patient’s  admission,  paracentesis  was  performed.  A bucket 
of  limpid  serum  was  drawn  from  the  abdomen.  Desirous  of  arousing  the  action 
of  the  kidneys,  in  order  to  prevent  the  peritoneal  collection  from  forming,  M. 
Lerminier  prescribed  the  usual  diuretic  preparations,  also  frictions  on  the  inside 
of  the  thighs  with  tincture  of  digitalis.  For  the  twelve  days  following  no  change 
of  any  moment  occurred  in  the  state  of  the  patient.  M.  Lerminier  then  pre- 
scribed a mixture,  consisting  of  an  ounce  of  castor  oil,  half  an  ounce  of  syrup  of 
buckthorn,  and  two  drachms  of  mint.  Very  copious  serous  stools  were  obtained, 
accompanied  with  severe  colicky  pains.  Twenty  days  after  the  paracentesis, 
the  ascites  was  much  greater  than  it  was  at  the  period  when  the  operation  was 
performed.  The  features  were  changed ; the  prostration  was  extreme  ; the 
tongue  retained  its  moist  state,  and  was  not  red.  At  the  commencement  of  Janu- 
ary it  began  to  become  brown  in  the  centre,  without  being  red  at  the  edges  ; 
the  pulse  continually  became  weaker,  and  the  patient  died  without  a struggle. 
The  extremities  had  never  been  infiltrated. 

Post-mortem . — An  enormous  quantity  of  limpid  serum  escaped  through 


DISEASES  OF  THE  ABDOMEN. 


353 


the  abdominal  parietes  when  cut  into.  No  flocculi  were  observed  to  float  in  it, 
and  there  was  no  indication  in  the  abdomen  of  any  previous  or  present  inflam- 
mation of  the  peritoneum.  We  were  struck  with  the  feeling  of  density  which 
the  liver  presented  externally  to  the  mere  touch  ; though  its  size  was  not  at  all 
increased,  it  was  much  heavier  than  usual.  It  had  a uniform  red  colour;  it 
could  not  be  torn  without  considerable  difficulty  ; and  with  respect  to  its  colour, 
its  smooth  section,  and  the  aggregate  of  its  physical  properties,  one  could  not 
compare  one  of  its  slices  to  anything  better  than  to  a slice  of  lean  ham.  The 
stomach  was  pale  throughout  its  internal  surface  ; its  mucous  membrane  was  so 
soft  and  thin  towards  the  great  cul-de-sac,  that  in  several  points  nothing  was 
found  but  the  submucous  cellular  tissue  lined  by  a liquid  and  whitish  pulp.  The 
duodenum  and  rest  of  the  small  intestine  presented  no  appreciable  lesion,  except 
here  and  there  some  partial  injections  of  the  mucous  membrane.  The  caecum 
presented  over  its  entire  surface  a brownish  tint,  and  considerable  development 
of  its  follicles.  The  mucous  membrane  of  the  colon  was  white  throughout; 
but  in  several  points  it  was  perceptibly  softened.  The  brownish  colour  reap- 
peared in  the  rectum.  Nothing  else  was  found  worth  noticing,  except  that  the 
lateral  ventricles  were  distended  with  a considerable  quantity  of  serum.  The 
heart  and  lungs  were  quite  healthy. 

We  find  in  this  case  an  alteration  in  the  texture  of  the  liver  different  from 
any  observed  in  the  preceding  cases.  Its  parenchyma  was  considerably  indu- 
rated, and  its  density  increased ; its  colour  was  of  a deeper  red  than  that  of  the 
liver  in  its  healthy  state.  To  discover  this  affection  we  find  no  characteristic 
symptom ; but  here  a new  morbid  phenomenon  presents  itself,  which  we  have 
not  seen  hitherto  ; namely,  ascites.  As  it  was  evidently  independent  of  disease 
of  the  heart,  and  as  there  was  nothing  to  indicate  that  there  had  been  peritonitis 
in  the  case,  one  might  suspect  that  it  must  depend  on  an  affection  of  the  liver ; 
but  of  this  there  was  no  certainty.  The  increased  consistence  of  this  organ 
probably  opposed  the  free  circulation  of  the  venous  blood  within  it.  There 
was  here  then  obstruction  of  the  liver,  a very  vague  term,  very  properly  banished 
from  scientific  language,  but  one  which  nevertheless  expresses  a real  fact.  There 
was  no  derangement,  at  least  perceptible  to  us,  of  the  biliary  secretion. 

The  period  when  this  disease  of  the  liver  commenced  it  is  not  easy  to  deter- 
mine. Was  its  commencement  announced  by  the  pain  felt  in  the  right  hypo- 
chondrium,  when  the  symptoms  of  pulmonary  irritation  were  succeeded  by 
other  symptoms  of  gastro-intestinal  irritation? 

The  white  softening  of  the  gastric  mucous  membrane  did  not  prevent  the 
tongue  from  constantly  retaining  a natural  state,  except  for  the  last  few  days 
before  the  patient’s  death,  when  it  became  brown.  There  had  been  some 
vomiting  at  the  commencement  of  the  disease.  But  at  a later  period  the  gastric 
symptoms  were  very  little  marked.  To  account  for  the  chronic  diarrhoea  no- 
thing was  found,  but  a brown  colouring  of  the  caecum  and  rectum,  and  a little 
white  softening,  similar  to  that  of  the  stomach,  in  the  mucous  membrane  of 
the  colon. 

One  may  see  in  this  case,  an  instance  of  the  effect  produced  by  repeated 
purgatives  and  other  irritants  administered  to  a person  who  had  ascites,  and 
whose  intestinal  mucous  membrane  was  already  in  a state  of  irritation.  On  this 
point  I shall  make  but  one  remark  ; namely,  that  those  stimulants  applied  to  a 
mucous  membrane  already  diseased  never  produced  fever. 

We  may  remark  the  very  healthy  state  in  which  the  lungs  were  found  in  a 
person,  who  for  several  months  before  had  had  hemoptysis  followed  by  cough. 
This  is  another  fact  which  proves  the  possibility  of  the  production  of  hemop- 
tysis without  the  existence  of  previous  tubercles.  What  was  also  very  remark- 
able here  was  the  sudden  disappearance  of  the  thoracic  symptoms  at  the  same 
time  that  the  abdominal  viscera  began  to  be  affected. 

30* 


351 


ANDIiAL’S  MEDICAL  CLINIC. 


Case  11. — Red  induration  of  the  liver,  with  development  of  granulations  at  its  circumference 

and  in  its  interior — Jaundice  and  ascites — Tumour  produced  by  the  left  lobe  of  the  liver — 

Supposed  cause  ; mental  emotion. 

A cab-driver,  forty-nine  years  of  age,  of  a strong  constitution,  who  had  in- 
dulged in  alcoholic  liquors  to  a great  excess,  enjoyed  good  health  up  to  the  end 
of  June,  at  which  time  he  had  a violent  dispute  with  some  of  his  comrades, 
after  which  he  became  yellow.  lie  entered  an  hospital,  and  after  remaining  in 
it  for  thirty-six  days,  he  left  it  with  a very  slight  yellow  tint  still  remaining. 
The  jaundice  soon  reappeared.  From  the  20th  to  the  30th  of  August  the  abdo- 
men began  to  swell.  In  September  the  ascites  increased,  and  the  lower 
extremities  then  became  infiltrated,  and  towards  the  20th  of  September  the 
dropsy  extended  to  the  scrotum. 

On  the  5th  of  October  he  entered  the  Charite.  At  this  time  the  entire  cuta- 
neous surface  was  of  a greenish-yellow  tinge  ; the  abdomen  was  very  much 
swollen,  and  there  was  evident  fluctuation  in  it ; no  pain  had  ever  been  felt 
there.  The  lower  extremities,  scrotum,  and  penis  were  infiltrated  ; the  respi- 
ration was  impeded,  arising  from  the  compression  of  the  diaphragm  by  the 
peritoneal  liquid.  The  thoracic  organs  were  found  on  examination  quite  healthy ; 
pulse  small,  a little  frequent;  skin  not  hot ; urine  scanty  and  of  a saffron  colour  ; 
The  tongue  was  moist  and  whitish  ; appetite  none  ; very  little  thirst;  only  one 
stool  in  the  twenty-four  hours,  which  was  of  good  consistence,  and  presenting 
the  colour  of  ashes.  Great  debility.  Everything  here  seemed  to  show  that 
the  dropsy  depended  on  the  disease  of  the  liver.  M.  Lerminier  endeavoured 
to  combat  this  by  establishing  a double  revulsion  on  the  kidneys  and  intes- 
tinal mucous  membrane,  in  order  to  which  he  prescribed  the  usual  diuretic 
medicines.  October  8th,  the  infiltration  of  the  scrotum  had  diminished;  but 
the  peritoneal  collection  was  still  increased  ; it  produced  considerable  embar- 
rassment in  the  respiration.  Paracentesis  was  performed,  and  a transparent 
lemon-coloured  fluid  escaped.  The  collapse  of  the  abdominal  parietes,  im- 
mediately after  the  operation,  allowed  us  to  detect  the  existence  of  a tumour  to 
the  left  of  the  xiphoid  cartilage,  which  could  not  be  exactly  circumscribed,  and 
which  seemed  to  belong  to  the  left  lobe  of  the  liver.  The  same  treatment  was 
continued,  and,  the  9th,  the  infiltration  of  the  lower  extremities  was  diminished 
considerably;  on  the  10th  we  observed  a continual  tendency  to  stupor;  during 
the  night  a profuse  diarrhoea  set  in.  On  the  morning  of  the  11th  there  was 
great  prostration  ; tongue  brown  at  its  centre,  and  pulse  very  frequent ; the 
entire  day  coma  was  observable,  and  considerable  diarrhoea.  On  the  12th  the 
breathing  was  very  much  hurried ; tongue  dry,  black  at  the  centre  ; pulse  thready. 
13th,  face  pale  and  very  much  changed.  Sinapisms  to  different  parts  of  the 
extremities  ; decoction  of  seneka,  with  some  drops  of  liquid  ammonia;  aether. 
He  died  shortly  after  the  visit. 

Post-mortem.  — Some  infiltration  of  the  lower  extremities;  deep  yellow 
colour  of  the  entire  skin.  Trifling  quantity  of  limpid  and  yellow  serum  in  the 
cavity  of  the  peritoneum.  The  right  lobe  of  the  liver  did  not  go  beyond  the 
edge  of  the  ribs.  The  left  lobe,  on  the  contrary,  occupied  below  and  to  the 
left  of  the  xiphoid  cartilage,  a space  as  broad  as  the  breadth  of  two  fingers  ; it 
did  not  extend  into  the  left  hypochondrium.  The  tissue  of  the  liver  was 
brownish  ; externally  it  was  marked  with  a number  of  granulations,  which 
were  also  found  in  the  interior  of  the  organ.  The  gall-bladder  was  filled  with 
a very  thick  bile. 

The  internal  surface  of  the  stomach  presented  a slate-coloured  tint  over  a 
great  portion  of  its  extent.  In  the  cranium  the  dura  mater  was  found  to  be 
of  a yellow  colour  ; a small  quantity  of  yellow  serum  in  the  ventricles.  In  the 
chest,  the  cavity  of  the  two  pleurae,  and  that  of  the  pericardium,  some  spoonsful 
of  yellow  serum.  Some  liquid  black  blood  in  the  cavities  of  the  heart.  The 


DISEASES  OF  THE  ABDOMEN.  355 

thoracic  duct  contained  some  yellow  fluid.  The  costal  cartilages  were  also  co- 
loured yellow. 

The  liver  here  presented  four  species  of  alteration  combined:  1st,  change  in 
its  colour  ; 2dly,  partial  increase  in  its  size  (in  the  left  lobe)  3dly,  increase 
in  its  density  and  consistence  ; 4thly,  development  of  granulations  on  its  cir- 
cumference and  in  its  interior. 

As  symptoms  of  these  changes,  we  find  : 1st,  a small  tumour,  which  from  its 
seat  might  be  readily  taken  for  a tumour  connected  with  the  stomach  ; 2dly, 
jaundice  ; 3dly,  dropsy,  which  commenced  at  the  peritoneum,  and  then  ex- 
tended to  the  extremities,  a course  different  from  that  of  dropsies  which  depend 
on  a disease  of  the  heart. 

There  was  no  pain  felt  at  any  period  of  this  disease.  The  jaundice  was  the 
first  symptom  which  appeared.  The  patient  had  not  yet  remarked  any  de- 
rangement in  his  health,  when  a strong  mental  excitement  gave  rise  to  jaundice. 
But  whilst  the  majority  of  jaundices  arising  from  a similar  cause  have  in  gene- 
ral nothing  alarming  in  them,  and  disappear  after  some  time,  without  leaving 
any  bad  traces  after  them ; here,  on  the  contrary,  the  jaundice  was  in  a manner 
only  the  first  signal  of  a change  in  the  intimate  texture  of  the  liver.  Was  the 
first  impression  made  on  the  duodenum,  which  transmitted  its  irritation  to  the 
liver?  Was  there  first  inflammation  of  the  bile  ducts,  and  an  obstacle,  by 
reason  of  the  swelling  of  their  mucous  membrane,  to  the  flowing  of  the  bile 
into  the  duodenum.  Did  this  intestine,  as  also  the  ductus  hepaticus  and  ductus 
choledochus,  remain  in  their  healthy  state  ? And  does  not  the  mental  excite- 
ment act  rather  by  directly  influencing  the  nerves  of  the  liver,  which,  being 
modified  in  their  action,  alter  the  biliary  secretion  and  prevent  it  from  being 
duly  performed  ? Hence  the  materials  of  the  bile  tarry  in  the  blood,  and  jaun- 
dice is  produced.  All  these  questions  may  be  discussed  ; but  what  should  not  be 
forgotten  is,  that  the  post-mortem,  examination  did  not  point  out  in  the  ductus 
hepaticus  and  choledochus  any  mechanical  cause  which  could  prevent  the  bile 
from  coming  into  the  duodenum  ; besides,  the  liver  still  secreted  a certain  quan- 
tity of  it,  for  the  ducts  were  tinged  with  it,  and  some  was  found  in  the  gall- 
bladder ; but  it  was  remarkable  for  its  deep  black  colour.  Thus  there  is  in 
this  respect  a great  difference  between  this  case  and  those  previously  cited, 
where,  even  in  the  bile  ducts,  nothing  was  found  but  a little  mucus. 

The  state  of  the  intestines  is  well  worthy  of  remark.  Their  mucous  mem- 
brane had  been  frequently  irritated  by  different  purgatives,  and  still  it  was  found 
white  ; thus  these  medicines  had  occasioned  only  a temporary  congestion. 
Compare  this  case  with  those  where,  after  a purgative  or  emetic  given  once,  in- 
tense inflammation  of  the  digestive  tube  is  produced  with  sympathetic  reaction 
on  other  organs,  the  production  of  adynamic  or  ataxic  symptoms,  &c.,  and  try 
after  this  to  lay  down  fixed  rules  for  the  administration  of  medicines.  It  is  not 
less  important  for  the  physician  to  know  the  degree  of  sensibility  or  irritability 
of  the  intestinal  mucous  membrane,  then  to  know  on  the  other  hand  that  there 
are  cases,  where,  though  stimulants  of  a more  less  active  nature  be  brought  in 
contact  with  it,  it  is  still  actually  impossible  to  produce  in  it  a state  of  inflamma- 
tion. We  may  refer  to  other  cases  also,  where  the  employment  of  purgatives 
has  not  only  not  been  injurious,  but  in  which  their  employment  has  been  actu- 
ally attended  with  beneficial  results.  AVhy  do  we  dwell  on  these  facts  ? Pre- 
cisely because  the  medical  doctrines  of  the  present  day  divert  the  attention  of 
practitioners  from  them,  and  it  is  useful  to  know  them  even  in  a physiological 
point  of  view. 

We  perceive,  moreover,  that  profuse  diarrhoea  took  place  here  during  the  last 
few  days  preceding  death,  without  there  being  any  lesion  of  the  intestinal  mu- 
cous membrane,  as  far  as  we  could  ascertain,  to  account  for  it. 

The  alteration  of  the  stomach  consisted  merely  in  a change  of  the  colour  of 


356 


ANDRAL’S  MEDICAL  CLINIC. 


the  mucous  membrane  : there  was  not  during  life  any  other  sign  of  gastric  affec- 
tion except  loss  of  appetite  ; but  we  have  already  seen  that  this  may  be  con- 
ceived (Case  11)  to  be  independent  of  a morbid  state  of  the  stomach,  though  it 
is  perfectly  true  that  it  most  frequently  depends  on  it. 

The  operation  of  paracentesis  was  attended  by  a remarkable  decrease  in  the 
infiltration  of  the  lower  extremities  ; but  this  decrease  of  dropsy  was  not  fol- 
lowed by  any  useful  result ; it  was,  on  the  contrary,  from  this  period  that 
adynamic  symptoms  appeared*  and,  the  patient  fell  into  a state  of  coma,  in  which 
he  died. 


SECTION  II. 

ALTERATION  IN  THE  NUTRITION  OF  THE  LIVER,  WITH  DIMINUTION  OF 

ITS  SIZE  (ATROPHY). 

Case  12. — Atrophy  of  the  liver — Ceilulo-fibrous  appearance  of  its  tissue — Chronic  gastro- 
enteritis. 

A steel-polisher,  thirty-six  years  of  age,  entered  the  Oharite  January  27. 
After  severe  domestic  trials,  he  quitted  Versailles,  where  he  lived,  and  came  to 
reside  in  Paris  in  a narrow  damp  street.  Till  then  he  had  enjoyed  good 
health  ; only  that  sixteen  years  before  he  had  had  an  affection  of  the  chest,  and 
he  was  subject  to  hemorrhoids  from  his  youth.  A little  time  after  coming  to 
Paris  he  lost  his  appetite  ; the  introduction  of  food  into  the  stomach  was  some- 
times painful;  it  was  vomited  occasionally,  and  at  intervals  purging  super- 
vened ; when  it  ceased  obstinate  constipation  followed.  This  person,  who  till 
then  was  rather  fat,  became  rapidly  emaciated.  Eighteen  months  after  these 
symptoms  connected  with  the  digestive  organs  commenced,  he  perceived  at  the 
same  time  that  his  face  and  extremities  became  more  and  more  emaciated  ; his 
abdomen,  on  the  contrary,  increased  in  size,  without  however  any  pain  being 
felt  in  the  part. 

When  we  saw  this  patient,  there  was  considerable  effusion  in  the  abdomen, 
which  occasioned  manifest  fluctuation.  The  lower  extremities  were  infiltrated 
(the  patient  assured  us  that  the  cedema  of  the  extremities  did  not  appear  till 
long  after  the  abdomen  began  to  swell).  The  abdomen  when  pressed  in 
different  parts  did  not  appear  painful ; the  face  was  pale  and  thin  ; the  tongue 
was  covered  with  a yellowish  coat,  without  any  redness ; acid  eructations  fre- 
quently took  place  ; the  taking  of  any  solid  food  or  wine  into  the  stomach  was 
followed  by  an  acute  pain  in  the  epigastrium  ; appetite  was  gone ; the  patient 
complained  chiefly  of  having  an  insurmountable  disrelish  for  bread  ; he  lived  for 
a long  time  on  milk  and  vegetables.  Since  the  last  month  the  diarrhoea  had 
been  constant;  from  eight  to  ten  stools,  consisting  of  a liquid  matter  resembling 
yellowish  water,  occurred  every  day  ; the  pulse  was  a little  frequent  without 
the  skin  being  hot ; the  urine  was  scanty,  of  a brownish  red  colour,  and  loaded 
with  sediment.  There  was  no  trace  of  jaundice,  and  the  colour  of  the  alvine 
evacuations  proved  that  the  bile  flowed  into  the  duodenum. 

The  existence  of  chronic  gastro-enterite  was  manifest ; it  performed,  no  doubt, 
a considerable  partin  the  progressive  emaciation  of  the  patient.  With  respect  to 
the  cause  of  the  dropsy,  it  escaped  our  investigation  ; but  it  appeared  to  be  con- 
nected with  an  affection  of  the  liver. 

During  the  two  following  months  we  saw  this  individual  become  more  and 
more  emaciated  ; the  dropsy  remained  stationary.  Whenever  we  attempted  to 
combat  it  by  diuretics  we  were  obliged  to  desist,  in  consequence  of  these  medi- 
cines producing  no  other  effect  but  that  of  increasing  the  gastro-intestinal  irrita- 


DISEASES  OF  THE  ABDOMEN. 


357 


trail.  Friction,  with  tincture  of  digitalis,  proved  ineffectual,  as  did  friction  with 
mercury  over  the  abdomen.  Ultimately  the  tongue  became  red  and  dry  ; the 
diarrhoea,  which  had  never  ceased,  became  more  profuse  ; delirium  set  in,  and  the 
patient  died. 

Post-mortem.  Face  and  upper  extremities  very  much  emaciated  ; infiltration 
of  the  lower  extremities,  scrotum,  penis,  and  abdominal  parietes  ; limpid  serum, 
a little  greenish,  accumulated  in  great  quantity  in  the  peritoneum;  the  intestinal 
convolutions  floating  in  the  midst  of  this  serum,  and,  as  it  were,  washed  by  it». 
No  trace  of  inflammation  in  the  serous  membrane. 

The  liver  was  remarkable  for*  its  extremely  small  size.  The  left  lobe  con- 
sisted merely  of  a thin  tongue  superadded  to  the  right  lobe.  The  latter  is  itself 
much  less  than  usual.  Externally  it  presents  a greyish-green  colour.  It  offers- 
unusual  resistance  when  cut  into ; in  some  parts  it  actually  creaks  under  the 
scalpel.  Scarcely  any  trace  of  the  two  substances  of  the  liver,  as  they  are 
ordinarily  found,  were  to  be  seen,  but  merely  a whitish  tissue,  very  dense,  of 
a cellulo-fibrous  appearance,  which  seemed  very  slightly  vascular.  In  the 
ductus  hepaticus  and  ductus  choledochus,  as  also  in  the  gall-bladder,  we  found 
some  yellow  bile,  not  at  all  thick.  The  parietes  of  the  gall-bladder  were  infil- 
trated. 

The  stomach  presented  in  its  two  portions  different  alterations.  Towards 
the  great  cul-de-sac  (splenic  portion)  the  mucous  membrane  was  very  much  in- 
jected (dotted  appearance),  without  being  either  perceptibly  softened  or  thick- 
ened. In  the  pyloric  portion  the  mucous  membrane  was  of  a brownish  tint ; 
it  was  wrinkled,  uneven,  considerably  thickened,  and  difficult  to  tear  ; beneath 
it,  near  the  pylorus,  we  found  the  cellular  tissue  more  dense,  and  thicker  than 
usual.  The  internal  surface  of  the  duodenum  presented  a brownish  tint,  similar 
to  that  of  the  stomach.  In  the  lower  fifth  of  the  ileum,  as  also  in  the  caecum, 
and  ascending  colon,  numerous  ulcerations  were  found,  the  ancient  date  of  which 
was  proved  tjy  the  thickening  and  brownish  colour  of  the  cellular  tissue  which 
constituted  the  bottom  of  them.  Between  them  the  mucous  membrane  was  con- 
siderably injected.  This  injection  existed  without  any  ulceration  in  the  transverse 
colon,  and  as  far  as  the  rectum.  The  heart  was  empty,  flaccid,  and  devoid  of 
colour.  A considerable  quantity  of  serum  was  found  in  the  cerebral  ventricles, 
and  at  the  base  of  the  brain. 

Here  again  was  a serious  alteration  of  the  liver,  the  formation  of  which  was 
not  announced  by  any  characteristic  symptom.  What  was  its  point  of  depart- 
ure? Did  it  precede  or  follow  gastro-intestinal  inflammation  ? had  the  mental 
vexations  experienced  by  the  patient  any  influence  on  its  development  ? was 
this  atrophy  of  the  liver,  this  change  of  its  natural  parenchyma  into  as  it  were  a 
cellulo-fibrous  tissue  ; were  these  alterations  of  nutrition  referable  to  an  inflam- 
matory process  ? are  they  not  rather  the  result  of  an  entirely  opposite  state  ? 
is  there  not  some  analogy  between  this  liver  diminished  in  size,  and  the  natural 
parenchyma  of  which  tends  to  become  changed  into  a cellular  and  fibrous  web, 
and  those  organs  which,  when  they  become  atrophied,  leave  nothing  behind 
them  but  cellular  tissue,  or  fibrous  cords  ? (Thymus  gland,  arteries  and  veins, 
etc.) 

This  liver,  thus  atrophied,  hardened,  and  changed  in  its  texture,  no  longer 
allowed  a free  passage  to  the  blood  of  the  vena  portae  ; thence  the  production  of 
ascites,  and  afterwards  that  of  oedema  of  the  lower  extremities. 

However,  changed  as  it  was,  and  deprived  of  a part  of  the  vessels,  which 
appeared  to  be  obliterated,  this  liver  still  secreted  bile,  and  no  jaundice  ever  took 
place.  In  the  following  case,  where  we  shall  find  an  alteration  of  the  liver  pre- 
cisely similar,  we  shall  detect  on  the  contrary  the  existence  of  jaundice.  Thus,* 
the  further  we  advance,  the  more  we  see  proofs  of  this  assertion  increase^  namely, 
that  the  production  of  jaundice  depends  on  other  conditions  than  the  nature  of 
the  change  in  the  liver. 


358 


ANDllAL’S  MEDICAL  CLINIC. 


The  redness  and  dryness  of  the  tongue  which  supervened  towards  the  ter- 
mination, the  increase  of  the  intestinal  flux,  the  prostration  which  accompa- 
nied these  symptoms,  depended  no  doubt  on  an  exasperation  of  the  old  inflam- 
mations of  the  digestive  passages  ; the  redness,  without  softening,  of  the  splenic 
portion  of  the  stomach,  was  probably  the  organic  lesion  which  corresponded 
with  this  exasperation.  It  is  probable  that  in  many  cases  the  stomach  may 
thus  become  congested  without  serious  symptoms  resulting  from  it ; but,  oc- 
curring in  an  individual  already  much  debilitated,  this  congestion  soon  termi- 
nated fatally. 

So  true  is  it  that  as  a general  principle  it  is  not  on  the  intensity  of  the  lesions 
that  the  severity  of  the  symptoms  depends,  but  rather  on  the  disposition  in  which 
these  lesions  find  the  individuals  in  whom  they  occur. 

Case  13. — Atrophy  of  the  liver,  with  cellulo-fibrous  appearance  of  its  tissue — Dropsy — Jaun- 
dice— Healthy  state  of  the  digestive  tube — Gangrenous  erysipelas  of  an  extremity. 

A jockey,  fifty-two  years  old,  had  an  ascites  and  considerable  infiltration  of  the 
lower  extremities  when  he  entered  the  Charite  ; moreover  the  conjunctivae  and 
the  entire  cutaneous  surface  presented  a greenish-yellow  tint.  He  stated  that  for 
several  years  back  he  had  been  dropsical  and  jaundiced.  He  had  been  losing  his 
strength  and  flesh  for  some  time,  without  his  appetite  being  ever  diminished,  when 
he  perceived  his  abdomen  increased  in  size,  nearly  at  the  same  time  he  began  to 
become  yellow.  He  assured  us  he  had  never  felt  any  pain  or  uneasiness  in 
the  region  of  the  liver  ; the  abdomen,  when  examined  with  the  hand,  was  not 
painful  in  any  part;  no  tumour  was  detected  in  it ; the  tongue  presented  its  na- 
tural appearance  ; the  appetite  was  retained ; the  introduction  of  food  into  the 
stomach  did  not  occasion  any  local  or  general  indisposition  ; the  stools  were 
scanty,  but  coloured  as  in  a person  in  perfect  health ; the  pulse  was  free  from 
frequency.  The  patient  was  in  very  good  spirits.  A few  days  after  his  ad- 
mission paracentesis  was  performed  ; during  the  three  weeks  following  it  was 
twice  repeated  ; but  each  time  the  peritoneal  liquid  was  reproduced  with  asto- 
nishing rapidity.  Different  diuretics  were  ordered,  but  without  any  increase  in 
the  urinary  secretion  following  their  employment.  Still  the  patient  became 
weak,  and  his  appetite  declined,  when  after  scarifications  being  made  on  the  two 
lower  extremities,  which  were  in  a state  of  considerable  oedema,  a livid  redness 
attacked  the  skin  of  the  right  leg  ; on  the  third  day  of  the  appearance  of  this 
redness,  the  skin  which  was  the  seat  of  it  became  gangrenous  ; at  the  same  time 
rapid  prostration  set  in.  Death  took  place  six  days  after  the  appearance  of 
erysipelas. 

Post-mortem.  The  liver  and  its  appendages  were  so  very  like  what  was 
described  in  the  preceding  case  (Case  12),  that,  to  avoid  repetition,  we  refer  to 
that  description.  A great  quantity  of  limpid  serum  was  found  in  the  peritoneum, 
without  any  trace  of  peritonitis. 

This  case,  in  which  we  find  an  alteration  of  the  liver  precisely  similar  to  that 
described  in  the  Twelfth  Case,  which,  like  the  latter,  presents  total  absence  of 
pain  in  the  region  of  the  liver,  ‘and  the  production  of  dropsy,  differs  from  it,  1°, 
in  the  existence  of  the  jaundice,  which  supervened,  though  during  life  the  bile 
seemed  to  flow  into  the  duodenum,  as  was  proved  by  the  nature  of  the  stools  ; 
2°,  this  case  differs  again  from  the  preceding  in  the  absence  of  all  symptoms  of 
gastro-enterite,  and  in  the  very  healthy  state  in  which  the  digestive  tube  was 
found  after  death. 

The  gradual  debility  of  the  patient  seemed  to  be  the  twofold  result  both  of  the 
affection  of  the  liver  and  of  the  loss  of  serum  sustained  by  the  patient,  the 
ascites  being  very  rapidly  reproduced  after  each  of  the  three  operations,  which 
were  performed  successively  in  a very  short  space  of  time.  These  operations 
of  paracentesis  were  really  attended  then  with  injurious  effects  ; for  without 


DISEASES  OF  THE  ABDOMEN. 


359 


them  the  blood  would  have  lost  less  serum.  We  see  here  again  that  diuretics 
proved  ineffectual.  It  may  be  readily  conceived  that  they  might  have  more 
influence  if  the  object  was  to  replace  one  active  secretion  by  another.  But  here 
it  was  necessary  to  be  able  to  remove  the  mechanical  obstacle,  which,  by  pre- 
venting the  blood  from  freely  traversing  the  liver,  forced  the  thinnest  part  of 
this  fluid  to  transude  through  the  venous  capillaries. 

Death  was  evidently  the  result  of  the  gangrenous  erysipelas  which  attacked 
the  skin  of  one  of  the  legs  after  the  scarification.  Surely  the  termination  of 
this  erysipelas  in  gangrene  will  not  be  here  attributed  to  an  excess  of  inflam- 
mation. 

Case  14. — Granulated  state  of  the  liver,  with  increase  in  its  density  and  diminution  in  its 
size — Dropsy — Absence  of  jaundice  and  of  pain — Gastro-intestinal  inflammation. 

A man,  sixty-seven  years  of  age,  who  had  indulged  all  his  life  in  the  exces- 
sive abuse  of  ardent  spirits,  beheld  his  house  pillaged  in  1814,  and  his  fortune 
destroyed.  Being  thus  reduced  to  a state  bordering  on  beggary,  he  had  the 
additional  misfortune  to  lose  several  of  his  children  ; however,  his  health  re- 
mained good  till  towards  the  middle  of  May,  1821.  He  then  perceived  that 
the  parts  around  the  ankles  became  cedematous.  This  (Edema  increased  up  to 
the  month  4 of  June,  at  which  time  the  patient,  feeling  himself  very  weak,  no 
longer  left  his  bed-room.  The  dropsy  extended  gradually  to  the  thighs  and 
abdomen ; the  breathing  always  remained  free  ; he  never  had  had  any  abdo- 
minal pain.  Towards  the  end  of  October  the  distension  of  the  abdomen  was 
enormous;  paracentesis  was  then  performed ; he  entered  the  Charite  on  the 
19th  of  December,  and  then  presented  the  following  state  : — emaciation  of  the 
face  and  extremities,  evident  fluctuation  in  the  abdomen,  which  is  very  much 
swollen,  and  also  free  from  pain  ; lower  extremities  considerably  swollen;  the 
skin  of  the  right  leg  of  a livid  red  colour,  and  presented  numerous  fissures, 
through  which  a considerable  quantity  of  serum  flowed  spontaneously.  The 
breathing,  which  till  then  was  free,  has  recently  become  embarrassed  (probably 
occasioned  by  the  pressure  on  the  diaphragm  by  the  serum  in  the  peritoneum). 
Slight  cough ; percussion  and  auscultation  do  not  detect  in  the  thoracic  organs 
any  appreciable  lesions  except  some  moist  bronchial  rale  in  different  points, 
more  especially  on  the  left,  posteriorly.  Pulse  very  small,  frequent,  and  pre- 
senting great  irregularity  with  respect  to  the  strength  and  return  of  the  pulsa- 
tions ; tongue  moist,  and  of  a bright  red  ; thirst  moderate  ; sufficient  appetite  ; 
stools  natural ; urine  scanty,  but  limpid.  (Diuretic  'mixture,  calomel  and 
soap  pills.) 

On  the  22d  paracentesis  was  performed.  A bucket  of  limpid  serum  was 
drawn  off.  Notwithstanding  the  collapsed  state  of  the  abdominal  parietes,  we 
could  discover  no  tumour  either  in  the  right  hypochondrium  or  elsewhere. 

From  the  22d  to  the  25th  the  patient  stated  that  he  found  himself  very  well ; 
but  on  the  morning  of  the  latter  day  a considerable  change  took  place  witli  re- 
spect to  the  state  of  the  digestive  passages.  He  now  felt  an  utter  dislike  for 
food;  the  tongue  was  dry  and  brown ; several  liquid  stools  had  taken  place; 
the  frequency  of  the  pulse  was  very  much  increased,  being  130  per  minute. 
The  same  medicines  were  continued.  On  the  twenty-sixth  the  features  were 
altered  ; great  prostration  was  now  observed  ; dryness  and  brown  colour  of  the 
tongue  increased ; very  painful  tenesmus  ; stools  slimy  and  bloody ; pulse 
scarcely  perceptible,  and  remarkably  irregular ; urine  red  and  turbid.  Reap- 
pearance of  the  ascites  (anodyne  and  demulcent  lavement,  leeches  to  the  anus, 
mucilaginous  ptisan).  No  change  from  the  26th  to  the  30th.  On  the  30th 
the  abdomen  was  as  large  as  it  was  before  paracentesis  was  performed : the 
operation  was  again  resorted  to,  after  which  the  patient  found  some  temporary 


360 


AN  DUAL’S  MEDICAL  CLINIC. 


relief ; but  the  day  after  the  prostration  was  greater  than  ever.  The  face  was 
very  much  emaciated  ; the  patient  felt  convinced  of  approaching  dissolution. 
He  had  constant  vomiting  during  the  day.  In  three  days  more  diarrhoea  set  in  ; 
the  pulse  became  still  weaker,  the  vomiting  continued,  and  the  patient  died 
without  evincingthe  least  disturbance  of  the  intellectual  functions. 

Post-mortem. — Great  marasmus  of  the  face  and  upper  extremities ; consider- 
able infiltration  of  the  thighs  and  legs  ; ascites. 

Liver  extremely  small,  occupying  but  a small  portion  of  the  right  hypochon- 
drium,  and  of  a brownish  colour.  When  viewed  externally,  it  appeared  as  if 
contracted  and  shrivelled.  When  cut  into,  it  presented  a very  dense  tissue. 
Instead  of  presenting  its  usual  red  colour,  separated  into  areolae  by  numerous 
lines  or  white  circumvolutions,  it  seemed  merely  to  consist  of  an  infinite  number 
of  granulations,  of  a brownish-green  colour,  of  the  size  of  a grain  of  millet, 
pressed  one  upon  another ; but  little  blood  flowed  from  it  when  cut  into.  A 
very  small  quantity  of  colourless  bile,  appearing  to  consist  merely  of  water, 
albumen,  and  a little  yellow  colouring  matter,  was  contained  in  the  gall-bladder. 
Nothing  remarkable  in  the  biliary  ducts. 

The  inner  surface  of  the  stomach,  which  was  distended  with  liquids,  presented 
an  almost  uniform  redness  from  the  cardia  to  the  vicinity  of  the  pylorus ; the 
seat  of  this  redness  was  the  mucous  membrane,  which,  being  a little  thickened, 
still  retained  its  ordinary  consistence.  The  whiteness  of  the  small  intestine 
formed  a striking  contrast  to  the  redness  of  the  stomach  ; only  to  the  extent  of 
a foot  above  the  caecum  there  appeared  on  the  internal  surface  some  small, 
reddish,  rounded  bodies,  which  seemed  to  be  mucous  cryptae  in  a state  of 
inflammation.  A blackish  colour  and  evident  thickening  of  the  mucous  mem- 
brane of  the  caecum  and  of  the  ascending  colon.  The  transverse  colon  was 
white  ; there  was  a redness  like  wine-lees  on  the  internal  surface  of  the  rest  of 
the  large  intestine,  as  far  as  its  anal  extremity.  This  redness  was  seated  entirely 
in  the  mucous  membrane,  which  was  three  times  its  natural  thickness ; its  con- 
sistence also  was  perceptibly  increased.  A considerable  quantity  of  liquid 
black  blood  filled  the  four  cavities  of  the  heart,  which  in  other  respects  was 
healthy  ; neither  was  there  any  appreciable  alteration  in  the  large  vessels  which 
proceed  from  this  organ  or  enter  it.  General  redness  of  the  bronchi ; a frothy 
colourless  serum  flowed  from  the  pulmonary  parenchyma  when  cut  into. 
Cranium. — Considerable  serous  infiltration  of  the  sub-arachnoid  cellular  tissue 
on  the  convexity  of  the  hemispheres.  The  central  substance  was  remarkably 
soft  (the  body  was  opened  seventeen  hours  after  death).  One  would  have 
said  that  this  substance  was,  as  it  were,  infiltrated  with  liquid.  From  the 
middle  of  the  internal  surface  of  the  corpus  striatum  of  the  right  side,  a small, 
whitish,  friable  body  arose,  about  the  size  of  a common  pea,  which  was 
depressed  to  the  depth  of  one  or  two  lines  in  the  grey  substance  of  the  corpus 
striatum,  which  was  perfectly  healthy  around  it. 

We  have  here  a remarkable  instance  of  that  peculiar  alteration  of  the  liver 
which  has  been  designated  a granulated  state  of  that  organ  — a state  which  had 
been  already  observed  by  Morgagni  in  several  dropsical  patients,  and  which 
seems  to  us  not  to  have  sufficiently  engaged  the  attention  of  modern  observers. 
Here  this  granulated  state  had  acquired,  if  we  may  so  say,  its  maximum  of  de- 
velopment. The  entire  parenchyma  of  the  liver  really  consisted  merely  of 
granulations  collected  and  grouped  one  upon  the  other.  Still  there  was  notone 
visible  on  the  outside  of  the  organ.  It  was  diminished  in  size,  and  seemed 
atrophied  ; but,  as  we  have  already  endeavoured  to  explain  above,  the  atrophy 
affected  only  one  of  the  anatomical  elements  of  the  liver,  whilst  one  or  several 
of  its  elements  seemed  to  be  hypertrophied,  from  whence  arose  the  appearance 
of  these  numberless  granulations. 

If  we  now  direct  our  attention  to  the  causes  which  might  exert  some  influence 


DISEASES  OF  THE  ABDOMEN. 


361 


on  this  remarkable  alteration  of  the  liver,  we  shall  find  them  to  be  the  abuse  of 
spirituous  liquors,  and  great  mental  distress,  occurring  at  a time  when  the  ner- 
vous system,  changed  from  its  normal  state,  has  a peculiar  tendency  to  modify 
the  digestive  apparatus  and  its  appendages  in  their  organisation,  functions,  and 
vital  properties.  There  is  no  proof  that  in  this  case  the  affection  of  the  liver 
was  preceded  by  an  acute  or  chronic  affection  of  the  digestive  tube.  The  com- 
mencement of  the  disease  of  the  liver  was  very  obscure  ; it  was  not  announced 
by  any  pain,  by  any  tumefaction  of  the  hypochondrium,  or  any  trace  of  jaun- 
dice ; the  only  thing  observed  was,  that  the  patient’s  strength  diminished,  he 
lost  flesh,  and,  after  these  phenomena  alone  denoted  for  a certain  time  that  an 
important  organ  was  affected,  traces  of  dropsy  appeared.  The  course  of  the 
latter  disease  was  not  that  usually  observed  in  diseases  of  the  liver.  Com- 
mencing at  the  interior  part  of  the  lower  extremities,  extending  progressively, 
and  from  below  upwards,  to  the  legs,  and  then  to  the  thighs,  attacking  the  peri- 
toneum only  consecutively,  would  not  one  have  said  that  it  depended  on  organic 
disease  of  the  heart?  A new  phenomenon  further  contributed  to  mislead  one 
with  respect  to  the  real  seat  of  the  disease,  namely,  the  great  irregularity  of  the 
pulse ; and  still  the  heart  was  free  from  all  organic  disease,  the  cause  of  the 
dropsy  being  seated  in  the  liver.  So  true  is  it  that  in  medicine  the  most  gene- 
ral rules  have  almost  always  their  exceptions. 

At  the  time  the  patient  entered  the  hospital  the  digestive  functions  did  not 
yet  appear  to  have  undergone  any  perceptible  change  ; at  a later  period  symp- 
toms of  gastro-intestinal  irritation  were  observed  to  appear:  as  in  the  majo- 
rity of  those  cases  where  the  latter  supervenes  at  an  advanced  period  of  chronic 
diseases,  it  rapidly  gave  rise  to  that  group  of  symptoms  which  constitute  one 
of  the  varieties  of  what  is  called  adynamic  fever.  There  were  here  well-marked 
dysenteric  symptoms,  and  the  autopsy  detected  the  existence  of  a very  serious 
inflammatory  alteration  of  the  termination  of  the  colon  and  rectum.  The  small 
tubercle  implanted  in  the  corpus  striatum,  the  existence  of  which  was  not  indi- 
cated durirtg  life  by  any  symptoms,  is  deserving  of  notice. 


ARTICLE  III. 

OBSERVATIONS  WITH  RESPECT  TO  ACCIDENTAL  PRODUCTIONS  ARISING 

IN  THE  LIVER. 

By  this  term  we  designate  every  solid  or  liquid  substance  formed  accidentally 
in  the  midst  of  the  parenchyma  of  the  liver,  such  as  fatty  matter,  pus,  tubercle, 
cancerous  substance,  serous  cysts,  and  hydatids. 

Of  these  several  products  some  most  commonly  appear  in  the  liver  only  after 
an  evident  process  of  inflammation  ; others  are  not  in  all  cases  so  evidently 
preceded  by  this  process  ; whilst  in  others  there  is  no  proof  that  inflammation 
ever  existed. 

We  shall  now  cite  a certain  number  of  cases  calculated  to  point  out  the  more 
or  less  characteristic  symptoms  occasioned  by  several  of  these  productions. 

We  shall  first  speak  of  abscesses  of  the  liver,  on  which  M.  Louis  has  recently 
published  somp  very  interesting  observations,  the  principal  results  of  which 
agree  with  those  to  which  our  own  observations  shall  lead. 

31 


362 


ANDilAL’S  MEDICAL  CLINIC. 


SECTION  I. 

CASES  OF  ABSCESSES  OF  THE  LIVER. 

Case  15. — Febrile  jaundice — Painful  tumefaction  of  the  right  hypochondrium — Purulent 

depositions  scattered  through  the  liver,  with  redness  and  softening  of  its  tissue  around  them — 

Healthy  state  of  all  the  other  organs. 

A woman,  twenty-nine  years  of  age,  felt,  seven  days  before  entering  the  hos- 
pital, general  indisposition,  lassitude,  then  a shivering,  which  lasted  for  about 
two  hours,  and  was  followed  by  an  intense  heat,  which  continued.  During  the 
first  two  days  no  symptom  characteristic  of  the  suffering  of  any  particular  organ 
was  observed.  On  the  third  day  she  felt  pain  in  the  liver  and  right  side  of  the 
chest.  On  the  fourth  and  fifth  day  this  pain  continued,  and  extended  into  the 
right  hypochondrium.  On  the  sixth  day  she  began  to  become  yellow  ; on  the 
seventh  her  state  was  as  follows: 

Yellow  tint  of  the  conjunctivae  and  face,  which  was  less  marked  on  the  skin 
of  the  rest  of  the  body ; pains  in  the  limbs ; fixed  pain  in  the  site  of  the  last 
ribs  of  the  right  side,  and  below  them  ; right  hypochondrium  tense,  and  painful 
on  pressure.  We  thought  we  discovered  an  ill-defined  tumour  in  this  part,  to 
the  extent  of  two  or  three  inches  below  the  edge  of  the  ribs  ; tongue  whitish, 
without  any  redness;  no  thirst,  nor  appetite  ; epigastrium  soft,  and  free  from 
pain  ; stools  scanty,  solid,  and  yellowish  ; urine  small  in  quantity,  of  an  orange 
colour  ; pulse  frequent  and  hard  ; skin  very  hot  and  dry.  She  feels  difficulty  in 
changing  her  position  ; intellects  dull.  She  complains  of  being  very  weak. 
The  painful  tumefaction  of  the  right  hypochondrium,  the  jaundice,  and  accom- 
panying fever,  seemed  to  indicate  the  presence  of  acute  hepatitis.  There  was 
no  proof  that  the  digestive  passages  were  affected  at  the  same  time.  (Twenty- 
four  leeches  to  the  anus  ; ptisan  diet.) 

On  the  8th  and  9th  day  all  the  symptoms  worse.  Eyes  dull  and  devoid  of 
expression  ; the  mouth  remained  half  open  ; answers  slow,  difficult,  and  inac- 
curate ; she  put  out  her  tongue,  and  forgot  it  between  the  lips.  The  entire 
skin  very  yellow  ; the  pulse  still  frequent  and  hard ; the  pain  and  tumefaction 
of  the  hypochondrium  continued. 

On  the  11th  and  12th  days  all  the  symptoms  of  ataxic  fever  wrere  observed  ; 
patient  comatose  ; pupils  very  much  dilated,  and  fixed  ; it  is  not  entirely  certain 
that  she  retains  the  faculty  of  seeing.  When  the  skin  of  the  extremities  is 
pinched,  she  retracts  them  quickly.  Skin  continually  hot  and  dry,  and  very 
yellow  ; pulse  very  frequent,  and  irregular  with  respect  to  its  strength.  Tongue 
dry,  and  not  red.  (The  dryness  may  depend  on  the  open  state  of  the  mouth.) 
Fifteen  leeches  behind  each  ear,  blisters  to  the  thighs,  &c. 

On  the  13th  day  ; symptoms  the  same,  abdomen  tympanitic;  constipation  ; 
involuntary  discharge  of  urine.  (Lavement  with  the  addition  of  half  a drachm 
of  sulphate  of  quinine.)  On  the  14th  day  all  the  symptoms  still  worse.  She 
died  during  the  night. 

Post-mortem.  The  entire  cutaneous  surface  of  a deep  yellow  colour.  Con- 
siderable embonpoint.  On  feeling  the  right  hypochondrium  we  circumscribed 
the  sharp  edge  of  the  liver  two  fingers’  breadth  below  the  edge  of  the  ribs. 
Abdomen  very  tympanitic. 

On  raising  the  abdominal  parietes  we  perceived  the  liver  pass  some  inches 
below  the  edge  of  the  ribs  ; it  did  not  extend  into  the  left  hypochondrium.  Ex- 
ternally it  was  of  a bright  red  colour,  and  on  three  points  of  its  convex  surface 
we  distinguished  small  spots  of  a yellowish  white  colour.  On  cutting  into 
each  of  these  spots,  we  penetrated  into  a small  abscess  which  might  contain  a 
filbert. 


DISEASES  OF  THE  ABDOMEN. 


363 


In  the  interior  of  the  liver  from  seven  to  eight  purulent  collections  were 
scattered,  the  largest  of  which  might  have  held  a filbert,  as  the  three  preceding, 
the  smallest  of  which  seemed  to  consist  merely  of  a drop  of  pus.  The  parietes 
of  the  cavities  in  which  the  pus  was  lodged  were  lined  merely  by  a thin  mem- 
branous layer  not  organised.  The  hepatic,  parenchyma  was  of  a bright  red 
colour  in  every  part,  and  was  evidently  softened.  A great  quantity  of  blood 
flowed  from  it  when  cut  into. 

The  large  intestine,  and  several  convolutions  of  the  small  intestine,  were  dis- 
tended with  gas.  In  the  chest  the  heart  was  found  filled  with  fibrinous  coagula 
of  great  consistence,  deprived  in  a great  measure  of  colouring  matter.  Some 
stony  concretions  in  the  bronchial  glands.  In  the  cranium  there  was  consider- 
able injection  of  the  subarachnoid  cellular  tissue  ; the  cortical  substance  was  of 
a rose  colour  ; some  red  points  were  observed  imthe  white  substance.  There  was 
about  a spoonful  of  limpid  serum  in  each  lateral  ventricle. 

This  case  of  abscess  of  the  liver  is  the  only  one  we  have  had  an  opportunity 
of  observing  unaccompanied  by  a lesion  of  other  organs.  The  hepatitis  lasted 
fifteen  days  at  most,  and  was,  consequently,  acute  in  its  nature  ; the  pus  was  not 
collected  in  the  liver  into  one  single  abscess;  but  several  small  abscesses  were 
found  in  this  organ,  some  on  its  surface,  others  in  its  substance.  M.  Louis  has 
seen  a similar  phenomenon  ; but,  in  the  cases  observed  by  him,  there  was  around 
the  pus  a false  membrane,  much  more  developed  than  that  which  we  found  here. 
In  this  case,  as  in  those  cited  by  M.  Louis,  the  parenchyma  of  the  liver  was  red 
and  softened,  not  only  around  each  abscess,  but  over  the  entire  of  the  organ. 
The  pus  had  not  that  colour  of  wine-lees  which  is  said  to  belong  to  pus  in  the 
liver.  It  was  of  a greenish  white  colour,  and  creamy,  like  healthy  pus  secreted 
in  inflamed  cellular  tissue. 

At  the  onset  of  the  disease  there  was  observed  merely  that  general  state  which 
exists  at  the  commencement  of  most  acute  affections  : then  the  symptoms  of 
hepatitis  became  developed  ; its  existence  was  indicated  chiefly  by  four  pheno- 
mena : pain  in  the  right  side  of  the  chest,  tumefaction  of  the  hypochondrium, 
jaundice  and  fever.  Any  one  of  these  signs,  even  the  jaundice  itself,  taken 
separately,  would  have  had  but  little  value  ; but  their  combination  attached 
considerable  certainty  to  the  diagnosis.  The  nature  of  the  stools,  the  examina- 
tion of  the  body,  also  concurred  in  proving  that  the  jaundice  was  not  here  de- 
pendent on  an  obstacle  to  the  course  of  the  bile,  and  that  the  latter  freely  entered 
the  duodenum.  Pain  preceded  the  appearance  of  the  jaundice. 

These  symptoms  alone  would  not  have  occasioned  death  in  so  short  a time. 
But  the  affection  of  the  liver  reacted  on  the  brain,  and  the  irritation  of  this  organ, 
which  was  altogether  sympathetic,  produced  the  most  serious  results  ; that  group 
of  symptoms  was  then  observed  which  characterise  ataxic  fever;  the  brain  affec- 
tion was  the  cause  of  death. 

The  post-mortem  examination  presented  a perfectly  healthy  state  of  the  diges- 
tive tube.  Thus,  in  this  case,  the  ataxic  fever  had  its  point  of  departure  solely 
in  the  liver;  and,  besides,  the  affection  of  the  latter  organ  was  wholly  indepen- 
dent of  disease  of  the  digestive  passages.  It  might  be  said,  to  be  sure,  that  at 
the  onset  there  was  gastro-enteritis,  and  that  on  this  depended  the  general  state 
of  the  patient  during  the  first  days  of  the  disease,  and  that  the  inflammation, 
attacking  the  liver,  left  the  intestine  ; but  this  is  mere  hypothesis. 

We  may  remark  that  the  meteorism  observed  in  this  individual,  towards  the 
termination  of  life,  was  independent  of  an  inflammatory  slate  of  the  parts  of 
the  intestine  where  it  was  seated. 

Case  16. — Abscess  of  the  liver  with  redness  and  softening  of  its  tissue — Painful  tumour  of 

the  right  hypochondrium,  supervening  during  the  progress  of  a chronic  gastro-enterite — No 

jaundice. 

A man,  thirty-nine  years  of  age,  experienced  for  the  last  three  years  nearly 


364 


AX  DUAL’S  MEDICAL  CLINIC. 


all  the  symptoms  of  a chronic  gastro-enterite.  At  first  his  appetite  frequently 
became  deranged,  and  left  him  from  time  to  time;  then  complete  anorexia  set 
in  ; feeling  of  weight  in  the  epigastrium,  and  sometimes  actual  pain  beneath  the 
xiphoid  cartilage,  and  towards  the  left  hypochondrium,  after  introducing  food 
of  any  kind  into  the  stomach  ; frequent  eructations  ; vomiting  from  time  to  time  ; 
constipation  and  diarrhoea  alternately.  The  stools  were  sometimes  serous,  and 
occasionally  bloody.  The  patient  gradually  lost  flesh  and  strength,  and,  since 
the  last  few  months,  a short  dry  cough  supervened.  He  was  very  much  ema- 
ciated when  he  entered  the  Charite.  Then  the  abdomen  was  soft  and  free  from 
pain.  (Rice-water  with  gum,  starch  enema,  with  some  drops  of  Rousseau’s 
laudanum,  etc.)  During  the  first  fifteen  days  he  presented  nothing  new  ; the 
continuance  of  his  cough  induced  us  to  examine  his  chest,  but  we  found  nothing 
morbid  in  that  part.  The  pulse  was  habitually  a little  frequent,  without  the 
temperature  of  the  skin  being  raised.  The  means  employed  to  check  the 
diarrhoea  having  failed,  we  had  recourse  to  astringent  tonics.  (Decoction  of 
simarouba,  pills  consisting  of  extract  of  rhatany  and  dragon’s  blood.)  But,  a 
few  days  after  the  employment  of  these,  the  abdomen,  hitherto  free  from  pain, 
became  painful ; fever  supervened  ; the  stools  were  tinged  with  blood.  We 
then  had  recourse  to  gum-water,  rice  ptisan,  Sydenham’s  white  decoction.  The 
stools  in  a little  time  became  purely  serous,  the  heat  of  skin  ceased,  and  the 
abdomen  was  no  longer  painful.  But,  in  a little  time,  other  symptoms  ap- 
peared ; after  a violent  attack  of  shivering,  a pain  more  remarkable  for  its 
extent  than  acuteness  was  felt  on  the  lower  and  right  side  of  the  chest,  and  at 
the  same  time  a continued  fever  set  in,  with  considerable  exacerbation  every 
evening.  At  first  we  thought  that  this  pain  and  the  accompanying  fever  were 
connected  with  pleuritis  ; and,  to  combat  it,  twenty  leeches  were  applied  to  the 
affected  side  ; afterwards  a large  blister  was  applied.  This  pain  and  fever  lasted 
for  eight  days  without  the  cough  being  increased,  and  without  there  being  any 
dyspnoea,  when  the  patient  complained  of  the  pain  extending  into  the  right 
hypochondrium.  We  examined  this  region,  and  actually  found  it  painful  to  the 
touch,  and  also  tense  and  swollen.  We  then  asked  ourselves  whether  the  case 
was  not  one  of  hepatitis,  and  whether  the  thoracic  pain,  fever,  and  great  anxiety 
of  the  patient,  did  not  depend  on  this  inflammation  rather  than  on  inflammation 
of  the  lung  or  pleura.  Still  there  was  not  the  least  appearance  of  jaundice. 
On  the  other  hand,  nothing  indicated  that  there  was  any  exasperation  of  the 
chronic  affection  of  the  digestive  passages  : the  tongue  was  remarkable  only  for 
its  paleness ; the  stools  retained  the  same  character.  Leeches  were  applied 
over  the  hypochondrium,  which  neither  rendered  it  softer  nor  less  painful.  Dur- 
ing the  nine  days  following  a tumour  was  observed  in  this  hypochondrium  to 
the  extent  of  some  fingers’  breadth  beneath  the  ribs.  Debility  increased  rapidly, 
profuse  diarrhoea  set  in,  and  he  died  in  a little  time. 

Post-mortem.  On  examining  the  right  hypochondrium  with  the  hand,  we 
thought  we  discovered,  in  the  situation  where  the  tumour  did  exist,  an  obscure 
fluctuation  ; a bistoury  was  plunged  into  it  before  the  abdominal  parietes  were 
removed,  and  a considerable  quantity  of  pus  gushed  out.  We  soon  felt  satisfied 
that  the  tumour  belonged  to  the  enlarged  liver,  which  descended  full  three  fin- 
gers’ breadth  beneath  the  ribs  ; the  bistoury  penetrated  into  a cavity  formed 
in  its  tissue  large  enough  to  contain  an  orange,  filled  with  good  creamy  pus. 
This  cavity  was  formed  in  the  very  substance  of  the  liver,  for  its  parietes  on 
every  side  consisted  of  the  tissue  of  this  organ  ; they  were  lined  with  a whitish 
membraniform  layer,  which  did  not  appear  to  be  organised.  Anteriorly,  over 
the  portion  of  the  liver  which  formed  the  tumour,  this  viscus  was  connected  to 
the  abdominal  parietes  by  soft  peritoneal  adhesions,  not  yet  organised  into  cel- 
lular tissue,  and  which  seemed  to  be  of  recent  formation.  No  other  trace  of 
peritonitis  was  found  in  the  rest  of  the  abdomen.  The  purulent  collection  just 
described  was  the  only  one  that  existed  in  the  liver ; but  the  tissue  of  this 


DISEASES  OF  THE  ABDOMEN. 


365 


organ  was  red  every  where,  and  remarkably  soft ; the  least  force  lacerated  it, 
and  the  slightest  pressure  reduced  it  to  a pap.  The  mucous  membrane  of  the 
stomach  was  actually  liquefied,  and  changed  into  a reddish  pulp  over  all  the 
great  cul-de-sac.  In  the  pyloric  portion  this  same  mucous  membrane  was  of  a 
slate  colour,  thickened  and  unequal  on  its  surface,  and  mammillated. 

The  duodenum  was  healthy,  as  also  the  upper  portions  of  the  small  intes- 
tine. In  the  lower  part  of  the  ileum,  and  in  the  caecum,  numerous  ulcerations 
were  found  of  an  irregular  form,  the  bottom  of  which  was  formed  of  thickened 
cellular  tissue,  and  the  edges  of  mucous  membrane  ; white  in  some  ; red,  livid, 
brown,  or  black,  in  others. 

In  the  upper  lobe  of  each  lung  some  crude  tubercles  were  found,  between 
which  the  pulmonary  parenchyma  was  healthy. 

Here  again  the  existence  of  hepatitis  coincided  with  that  of  gastro-enterite, 
but  the  latter  was  chronic,  and  it  was  only  after  it  had  been  in  existence  for 
years  that  the  liver  appeared  to  begin  to  suffer  irritation.  Probably  the  stimu- 
lating medicines  employed  in  order  to  combat  the  diarrhoea,  had  some  influence 
on  the  development  of  the  affection  of  the  liver.  It  certainly  was  a little  time 
after  the  administration  of  the  decoction  of  simarouba,  and  the  other  medi- 
cines, that  a pain  was  felt  towards  the  region  of  the  liver,  and  that  the  right 
hypochondrium  became  swollen.  Such  were  the  only  signs  which  announced 
the  hepatitis  ; there  never  was  jaundice  ; even  the  urine  did  not  become  coloured, 
so  that,  before  the  appearance  of  the  tumour  in  the  hypochondrium,  the  pain 
on  the  right  side  of  the  chest,  accompanied  by  a high  fever,  might  have  been 
referred  to  an  intercurrent  inflammation  of  the  pleura  : it  must  be  remarked, 
however,  that  there  was  no  dyspnoea ; but  dyspnoea  does  not  always  exist  in 
pleuritis.  Why  was  there  no  jaundice  in  this  case,  when  it  was  observed  in 
the  preceding  cases  where  the  same  lesions  existed  ? This  we  are  unable  to 
determine. 

Here,  again,  we  find  the  liver  red  and  softened,  at  the  same  time  that  it  con- 
tained a cavity  full  of  pus.  This  cavity  was  very  superficially  situated  ; ad- 
hesive inflammation  was  developed  between  the  point  of  the  external  surface 
of  the  liver  beneath  which  it  existed  and  the  abdominal  parietes  ; under  such 
circumstances  the  latter  might  also  have  become  inflamed  in  their  turn,  and  in 
consequence  of  the  tendency  of  pus,  as  of  every  foreign  body,  to  make  its  way 
to  the  exterior,  it  might  have  escaped  through  the  abdominal  parietes. 

This  superficial  situation  of  the  abscess  gave  rise,  where  it  did  exist,  to  an 
obscure  fluctuation,  which  was  recognised  only  on  the  dead  body,  and  which, 
if  ascertained  during  life,  might  have  led  us  to  diagnose  the  presence  of  an  ab- 
scess in  the  liver.  However,  it  might  have  still  been  a question  whether  this 
fluctuation  was  the  result  of  an  abscess  formed  in  the  hepatic  parenchyma,  or 
whether  it  was  not  owing  either  to  a sac  of  hydatids  developed  in  the  liver  ; but 
then  the  tumour  would  not  have  been  formed  with  so  much  rapidity  ; or  to  the 
gall-bladder  filled  with  some  liquid,  but  one  might  have  detected  its  form,  and 
could  have  circumscribed  it ; or  to  an  encysted  abscess  of  the  peritoneum. 

We  shall  again  direct  the  reader’s  attention,  1st,  to  the  lesions  found  in  the 
digestive  tube  of  an  individual,  who  for  the  last  three  years  presented  the  signs 
of  a chronic  gastro-enterite  ; 2dly,  to  the  healthy  state  of  the  duodenum,  not- 
withstanding the  serious  disease  of  the  liver  ; 3dly,  to  the  total  absence  of 
abdominal  pains,  notwithstanding  the  existence  of  numerous  ulcerations 
in  several  points  of  the  intestine  (this  is  the  most  common  case  when  these 
ulcerations  are  formed  chronically,  and  even  when  they  succeed  to  acute  inflam- 
mation) ; 4thly,  to  the  bad  effects  produced  by  astringent  tonics,  which  excited 
fever,  occasioned  pains  in  the  abdomen,  and  produced  bloody  stools  ; 5thly,  to 
the  well-marked  difference  which  existed  with  respect  to  the  nature  of  the  lesions 
31* 


366 


ANDKAL’S  MEDICAL  CLINIC. 


between  the  splenic  and  pyloric  portions  of  the  stomach  ; 6thly,  to  the  tubercles 
developed  in  the  lung,  the  existence  of  which  could  not  have  been  suspected. 
In  this  respect  it  is  a case  similar  to  those  of  which  we  have  cited  several  in- 
stances in  this  work,  and  in  which,  according  to  a course  the  reverse  of  that 
most  ordinarily  observed,  pulmonary  phthisis  is  developed  consecutively  to  what 
might  be  called  intestinal  phthisis.  It  is  further  to  be  remarked  that,  notwith- 
standing the  long  continuance  of  the  intestinal  inflammation,  there  were  no 
tubercles  developed  either  in  the  coats  of  the  intestine,  or  in  the  corresponding 
mesenteric  glands  ; and  still  there  was  evidently  a predisposition  to  the  forma- 
tion of  these  tubercles,  since  the  lungs  contained  some. 

Case  17. — Numerous  abscesses  in  the  liver,  with  redness  and  softening  of  the  parenchyma 

around  them — Absence  of  jaundice,  pain,  and  swelling — Acute  inflammation  of  the  left  lung 

and  stomach. 

A middle-aged  woman  was  in  the  enjoyment  of  good  health,  when  she  was 
attacked  with  a stitch  in  the  side  beneath  the  left  mamma,  all  the  characteristic 
signs  of  acute  pleuro-pneumonia  soon  appeared.  We  saw  her  five  days  after  the 
attack  of  the  stitch  in  the  side  ; the  breathing  was  then  very  much  impeded  ; 
her  countenance  indicated  the  most  intense  anxiety ; cheeks  flushed,  without 
there  being  the  least  appearance  of  jaundice.  The  sputa  were  rust-coloured, 
viscid,  uniting  into  a transparent  mass,  which  adhered  to  the  vessel,  and  could 
not  be  detached  even  by  inverting  it.  This  woman’s  reluctance  to  submit  to 
examination  prevented  us  from  percussing  or  auscultating  her  with  sufficient 
accuracy.  There  was  intense  fever,  and  also  some  signs  of  gastric  complica- 
tion, such  as  red,  smooth,  and  dry  tongue,  great  thirst,  some  vomiting  from  the 
onset  of  the  disease,  pain  in  the  epigastrium  from  slight  pressure.  The  rest  of 
the  abdomen,  and  particularly  the  right  hypochondrium,  was  soft  and  free  from 
pain.  No  pain  had  been  felt  in  the  chest. 

During  the  six  days  following  venesection  was  employed,  blisters  to  the 
lower  extremities,  and  emollient  drinks.  The  disease  became  worse,  dyspnoea 
increased,  the  sputa  were  no  longer  viscid,  but  took  on  the  appearance  of  prune 
juice.  The  patient  died  on  the  thirteenth  day  after  the  commencement  of  the 
stitch  in  the  side.  Up  to  the  last  moment  there  was  no  jaundice,  nor  had  any 
pain  been  complained  of  in  the  region  of  the  liver. 

Post-mortem. — Cranium.  Subarachnoid  cellular  tissue  was  infiltrated  with 
so  much  serum  that  the  arachnoid  was  raised  several  lines  by  it ; this  serum 
was  very  transparent ; a considerable  quantity  of  it  was  also  found  in  the 
ventricles. 

Chest.  The  lower  lobe  of  the  left  lung  presented  a mixture  of  red  and  grey 
hepatisation.  The  pleurae  pulmonalis  and  costalis  of  this  side  were  united  by 
soft  adhesions.  A little  pus  was  found  between  the  laminae  of  the  anterior 
mediastinum  behind  the  sternum. 

Abdomen.  The  liver  was  of  the  ordinary  size  ; when  viewed  externally  it 
appeared  healthy.  Incisions  were  made  in  several  parts  of  it,  which  detected 
no  disease  at  first,  but  on  making  another  we  detected  an  abscess  of  sufficient 
size  to  contain  a kidney-bean,  surrounded  for  some  lines  by  a red  and  softened 
tissue.  On  pursuing  our  researches  we  detected  nine  other  abscesses  within 
the  substance  of  the  liver,  one  of  which  might  contain  a large  nut ; the  others 
might  hold  a kidney-bean,  a nut,  or  a pea.  The  pus  which  they  contained  was 
of  a greenish  white  colour,  like  the  pus  of  a phlegmon.  A soft  false  membrane, 
not  organised,  resembling  solidified  pus,  lined  the  parietes  of  these  abscesses. 
Around  each  of  them,  to  the  extent  of  two  or  three  inches,  the  hepatic  paren- 
chyma was  softened,  and  of  a much  deeper  red  colour  than  in  the  other  points 
situate  at  a greater  distance  from  the  abscesses. 


DISEASES  OF  THE  ABDOMEN. 


367 


The  mucous  membrane  of  the  stomach  presented  some  bright  red  dots  along 
the  small  curvature  and  on  the  great  cul-de-sac.  In  this  part  also  it  was 
softened  ; one  could  remove  it  in  shreds.  Nothing  was  found  in  the  rest  of  the 
digestive  tube  but  a slight  vascular  injection  at  intervals.  In  the  place  of  one 
of  the  ovaries  nothing  was  found  but  a serous  pouch,  large  enough  to  contain 
an  apple.  A large  fibrous  body,  the  size  of  a nut,  was  found  within  the  uterus, 
beneath  the  proper  tissue  of  this  organ  and  the  peritoneum. 

We  do  not  here  find  any  sign  which  could  have  induced  us  even  to  suspect 
the  existence  of  any  affection  of  the  liver  ; there  was  not  the  least  trace  of 
jaundice  ; no  tumour  was  observed  in  the  right  hypochondrium,  nor  pain  in  the 
hepatic  region.  The  changes  found  in  the  liver,  similar  in  their  nature  to  those 
described  in  the  preceding  cases,  differ  from  them  in  extent  and  arrangement. 
The  abscesses  were  small,  but  very  numerous,  and  it  was  only  in  the  vicinity 
of  each  of  them  that  marks  of  an  inflammatory  process  (redness  and  softening) 
were  found.  Thus  in  this  individual  there  were  ten  abscesses  scattered  through 
the  liver,  but  which,  taken  together,  would  not  constitute  an  inflammation  of 
any  considerable  extent.  It  may,  however,  be  reasonably  admitted  that  the 
absence  of  jaundice  depended  on  this  circumstance,  that  a portion  of  the  hepatic 
parenchyma  had  remained  healthy. 

There  is  nothing  to  show  whether  the  affection  of  the  liver  in  this  case  was 
acute  or  chronic  ; whether  it  existed  long  before  the  twofold  inflammation  of 
the  lung  and  stomach  ; or  whether  it  supervened  at  the  same  time.  On  the  first 
hypothesis  it  would  be  necessary  to  admit  that  many  points  of  the  hepatic  pa- 
renchyma might  be  attacked  with  inflammation,  and  become  the  seatof  abscesses, 
without  the  health  being  in  any  way  affected,  which,  though  not  impossible,  is 
scarcely  probable.  On  the  one  hand  the  appearance  of  the  membrane  lining 
the  parietes  of  each  abscess  did  not  seem  to  indicate  that  the  latter  was  of  a 
longstanding.  We  would,  therefore,  be  inclined  to  think  that  the  hepatitis 
commenced  at  the  same  time  as  the  gastritis  and  the  pleuro-pneumonia  ; if  this 
be  correct,  the  case  just  cited  would  afford  an  instance  of  inflammation  of  the 
liver,  terminating  in  suppuration,  from  the  twelfth  to  the  thirteenth  day  after  its 
commencement;  but  we  entertain  some  well-founded  doubts  regarding  the 
period  at  which  pus  began  to  form  in  the  liver. 

Case  18. — Abscess  of  the  liver,  with  loss  of  colour  and  general  softening  of  its  tissue — Pain 

of  long  standing  on  the  right  side  of  the  chest — Chronic  nephritis — Acute  entero-colitis 

towards  the  termination. 

A woman,  about  fifty  years  of  age,  had  been  voiding  purulent  urine  for  the 
last  three  years  ; she  felt  habitual  pain  in  the  region  of  the  right  kidney  ; be- 
sides, nearly  since  the  same  period,  she  felt  another  pain,  very  distinct  from 
the  preceding,  under  the  last  ribs  of  the  right  side  ; this  pain,  which  was  in 
general  slight,  became  occasionally  very  acute.  She  wasted  away  gradually, 
and  when  we  saw  her  she  was  in  a very  advanced  stage  of  marasmus.  She  had 
never  had  jaundice.  Her  countenance  was  pale,  jaws  hollowed,  the  eyes  sunk 
in  their  orbits,  deep  ulceration  existed  on  one  of  the  transparent  corneae.  She 
was  so  weak  for  several  months  back  that  she  was  obliged  to  keep  her  bed. 
All  the  right  flank  was  painful  to  the  touch  ; it  was  evidently  tense,  more  promi- 
nent than  the  other ; no  tumour  could  be  circumscribed.  From  time  to  time 
the  patient  felt  a very  acute  pain,  which  generally  lasted  for  some  minutes,  and 
which  seemed  to  follow  the  course  of  the  ureter.  The  urine,  which  was  in 
tolerable  quantity,  presented  a whitish  sediment,  which  seemed  to  consist  of 
pus.  In  the  site  of  the  last  ribs  of  the  right  side,  both  anteriorly  and  poste- 
riorly, the  patient  complained  of  another  pain,  which  was  not  accompanied 
either  by  cough  or  dyspnoea.  The  right  hypochondrium  was  soft  and  free 
from  pain,  as  well  as  the  rest  of  the  abdomen.  Tongue  pale,  without  any  coat- 


368 


ANDRAL’S  MEDICAL  CLINIC. 


ing  ; no  thirst,  appetite  very  small ; stools  scanty,  consistent,  and  generally  of 
a brown  colour.  In  the  course  of  the  day  there  was  a little  frequency  of  the 
pulse,  without  any  increase  in  the  temperature  of  the  skin ; but  every  evening 
some  febrile  disturbance  set  in  ; it  sometimes  commenced  by  a little  shivering, 
and  never  terminated  in  a sweat. 

This  woman  was  considered  as  labouring  under  chronic  inflammation  of  the 
right  kidney.  With  respect  to  the  pain  which  she  felt  about  the  last  ribs  on  the 
right  side,  we  were  inclined  to  think  that  it  depended  on  a chronic  inflammation 
of  a portion  of  serous  membrane,  either  of  the  perihepatic  peritoneum  or  of  the 
pleura. 

The  long  standing  of  the  disease,  the  hectic  fever,  and  the  emaciated  state  of 
the  individual,  rendered  the  prognosis  very  unfavourable  ; recovery  seemed 
impossible : a palliative  treatment  was  all  that  could  be  adopted.  (Barley 
ptisan,  narcotic  cataplasms  around  the  right  flank,  sinapisms  from  time  to  time 
over  the  lower  extremities,  light  nourishment.)  The  state  of  the, patient  became 
worse  and  worse  ; the  marasmus  continually  increased,  and  the  debility  became 
extreme.  Diarrhoea  now  set  in  ; stools,  resembling  water  coloured  yellow,  to 
the  number  of  eight  or  ten  in  twenty-four  hours,  not  accompanied  with  abdo- 
minal pains.  Ten  days  after  she  died.  Up  to  the  last  moment  the  tongue 
remained  pale  and  moist  ; the  intellectual  faculties  remained  intact ; no  embar- 
rassment of  the  respiration  was  observed. 

Post-mortem.  Extreme  marasmus. 

Abdomen.  The  right  kidney  was  remarkably  large.  It  consisted  merely  of 
an  immense  pouch  filled  with  pus,  divided  into  several  compartments,  and 
communicating  freely  with  the  pelvis  ; the  interior  of  the  latter  was  also  full  of 
pus  ; its  surface  was  red,  as  also  that  of  the  ureter.  There  was  also  found  in 
the  fundus  of  the  bladder  some  redness,  in  the  form  of  small  spots,  to  ihe  num- 
ber of  five  or  six,  between  which  the  mucous  membrane  was  white.  A sero- 
purulent  liquid  was  infiltrated  into  the  intermuscular  and  subcutaneous  cellular 
tissue  of  the  posterior  parietes  of  the  right  flank. 

Liver  not  larger  than  usual  ; but  its  tissue  was  everywhere  of  a pale  grey 
colour,  and  so  softened  that  the  finger,  on  pressing  it,  sunk  into  it,  and  reduced  it 
to  a greyish  pulp  ; very  little  blood  flowed  from  it  when  cut  into.  Towards  the 
centre  of  the  right  lobe  there  was  a cavity  which  might  have  contained  a hen’s 
egg,  and  which  was  filled  with  a whitish  inodorous  pus,  resembling  the  healthy 
pus  of  phlegmons.  The  parietes  of  this  cavity  were  lined  by  a false  membrane, 
which  was  very  dense  and  thick,  consisting  of  an  assemblage  of  fibres  interlacing 
in  different  directions.  Immediately  around  this  abscess  the  liver  was  not  redder 
than  elsewhere. 

The  mucous  membrane  of  the  stomach  was  a little  softened  towards  the  great 
cul-de-sac.  The  mucous  membrane  of  the  ileum,  to  the  extent  of  about  two  feet 
above  the  caecum,  and  also  a considerable  portion  of  the  colon,  presented  a bright 
red  appearance,  with  softening  of  its  tissue  in  some  points. 

The  pleurae  presented  no  trace  of  inflammation  except  towards  the  summitof 
the  left  lung  ; there  we  found  a sort  of  coif,  of  cartilaginous  consistence,  around 
the  lung  ; beneath  it  the  pulmonary  parenchyma  was  hard  and  black. 

In  the  disease  whose  history  has  been  now  traced  it  seems  that  the  affection 
of  the  liver  performed  but  a very  secondary  part.  No  doubt  this  affection  con- 
tributed to  the  emaciation  of  the  subject ; but  during  life  the  nephritis  alone  gave 
characteristic  signs  of  its  existence.  The  pain  felt  towards  the  hepatic  region 
might  in  fact  be  referred  to  several  parts,  and  by  itself  it  could  not  indicate  a 
disease  of  the  liver. 

The  change  which  this  organ  underwent  differs,  in  some  respects,  from  that 
found  in  the  preceding  cases.  Here  too,  no  doubt,  pus  was  formed  ; around 
the  abscess,  and  over  the  remainder  of  the  hepatic  parenchyma,  there  was  also 


DISEASES  OF  THE  ABDOMEN. 


369 


marked  softening  of  the  tissue  of  the  liver ; but  this  organ,  far  from  being  redder, 
was,  on  the  contrary,  much  paler,  and  contained  much  less  blood  than  in  its  normal 
state. 

We  have  already  detected  in  other  cases  the  existence  of  a similar  softening 
of  the  liver,  with  evident  loss  of  colour  in  its  tissue.  We  then  hesitated  to  pro- 
nounce whether  it  was  an  inflammatory  lesion.  Here  the  coexistence  of  an 
abscess  with  a similar  state  of  the  liver  seems  to  prove  the  inflammatory  nature 
of  this  state,  though  in  our  opinion  it  does  not  prove  it  sufficiently.  May  not 
two  affections  of  a different  nature  exist  simultaneously  in  an  organ  ? We  must 
not  suppose  that  we  are  necessarily  to  find  inflammation  around  an  abscess  ; 
we  have  seen  more  than  one  case  in  which  the  organ  in  which  the  abscess  was 
presented  no  other  trace  of  lesion  but  this  abscess  itself. 

No  doubt  but  the  disease  of  the  liver  in  this  individual  followed  a very  chronic 
course.  The  long  continuance  of  the  pain  might  alone  prove  it ; but  we  have 
an  additional  proof  of  the  fact  in  the  texture  of  the  false  membrane  which  lined 
the  parietes  of  the  abscess. 

Here  again  an  acute  inflammation  terminated  the  patient’s  life.  The  diar- 
rhoea which  succeeded  an  habitual  constipation  was  the  only  sign  of  the  acute 
entero-colitis,  the  existence  of  which  was  proved  by  the  post-mortem  examina- 
tion. This  serous  diarrhoea,  which  came  on  without  any  pain,  in  an  individual 
already  worn  out  by  a lingering  disease,  would  have  been  classed  some  years 
ago  in  the  number  of  what  are  called  colliquative  sweats,  and  considered  as  totally 
independent  of  inflammation  ; the  latter,  however,  was  real.  No  doubt  the  in- 
flammations which  come  on  under  such  circumstances  are  not  connected  with  a 
plethoric  state  ; but  it  must  be  admitted  as  a fact,  that  however  small  the  quan- 
tity of  blood  is  which  remains  in  the  system,  and  however  exhausted  the 
strength  of  the  patient  may  seem  to  be,  there  is  nevertheless  a very  ready  and 
very  frequent  afflux  of  this  residue  of  blood  and  strength  towards  different  irri- 
tated points,  and  particularly  towards  the  gastro-intesiinal  mucous  membrane. 
It  would  seem  that,  from  the  mere  circumstance  of  the  primary  chronic  affec- 
tion having  destroyed  the  equilibrium  of  the  healthy  state,  there  is  a constant  ten- 
dency to  an  unequal  distribution  of  life  and  blood  in  the  different  organs. 

Case  19. — Abscess  of  the  liver  opening  into  the  stomach— Symptoms  of  chronic  gastritis — 

Jaundice  at  the  onset. 

We  possess  but  little  information  with  respect  to  the  case  of  the  individual 
here  referred  to ; we  know,  however,  that  when  he  entered  the  Charite  he  had 
been  for  a long  time  complaining  of  anorexia,  pain  in  the  epigastrium,  never  of 
vomiting,  frequent  accessions  of  fever,  and  that  he  was  very  much  emaciated. 
The  skin  was  merely  pale ; but  two  years  before,  towards  the  commencement 
of  his  illness,  the  patient  had  had  jaundice,  which  lasted  four  months. 

The  post-mortem  examination  presented  the  following  lesions  : 

1st.  In  the  cranium,  ossification  of  a considerable  portion  of  the  falx  of  the 
dura  mater.  (The  patient  was  scarcely  forty  years  of  age.) 

2d.  In  the  chest,  some  tubercles  scattered  through  the  pulmonary  parenchyma, 
which  in  other  respects  was  healthy. 

3d.  In  the  abdomen,  close  adhesions  between  the  liver  and  stomach.  On  the 
interior  the  latter  viscus  presented,  towards  its  posterior  surface,  a solution  of 
continuity  which  involved  all  its  tunics,  about  the  breadth  of  a two-franc  piece, 
through  which  a probe  being  introduced  penetrated  into  a cavity  in  the  liver 
large  enough  to  contain  an  orange,  and  which  was  filled  with  genuine  pus.  The 
parietes  of  this  cavity  were  lined  with  a thick  membrane,  which  seemed  to  be 
of  a fibro-mucous  texture. 

The  perforation  of  the  stomach  seemed  to  be  from  without  inwards  ; the  in- 


370 


ANDRAL’S  MEDICAL  CLINIC. 


flammation  extended  at  first  from  the  liver  towards  the  peritoneum  situate 
between  it  and  the  stomach,  and  occasioned  the  formation  of  adhesions  between 
these  two  organs  ; at  a later  period  the  coats  of  the  stomach  became  in  their 
turn  inflamed  in  a circumscribed  portion  of  their  extent ; and  the  peritoneal, 
cellular,  muscular,  and  mucous  membranes  became  successively  and  simultane- 
ously destroyed.  So  that  this  differs  from  other  more  common  cases,  in  which 
an  ulceration  forming  in  the  stomach  from  within  outwards,  ultimately  destroys 
all  the  tunics  of  the  stomach  at  the  point  where  it  first  commenced  ; and  then  the 
parietes  of  the  stomach,  completely  destroyed  at  this  point,  are  supplied  either 
by  the  liver,  or  by  the  pancreas,  &c. 

Be  this  as  it  may,  the  purulent  cavity  formed  in  the  liver  must  naturally 
empty  itself  in  part  into  the  stomach.  Would  pus  have  been  found  in  the 
alvine  evacuations  ? It  should  be  observed  that  the  opening  which  communi- 
cated between  the  interior  of  the  stomach  and  the  hepatic  abscess  was  still  in- 
considerable, and  had  probably  existed  but  for  a short  time.  The  nature  of  the 
stools  alone  might  have  thrown  some  light  on  this  latter  point.  Under  such 
circumstances  could  the  parietes  of  the  abscess  have  approximated  gradually, 
according  as  it  emptied  itself  into  the  stomach  ? If  that  had  occurred,  we  may 
easily  conceive  that  the  cure  of  the  liver  disease  would  not  have  been  impossible. 

We  should  not  forget  to  remark  that,  in  the  case  now  detailed,  no  appreciable 
alteration  of  the  liver  existed  except  where  the  abscess  was  ; we  have,  however, 
no  hesitation  in  considering  this  as  having  been  produced  by  an  inflammatory 
process.  But,  suppose  a hard  substance,  encephaloid  tissue,  for  instance,  exist- 
ing in  this  way  in  the  midst  of  the  liver,  without  any  alteration  in  the  texture 
of  the  organ  around  it,  this  latter  circumstance  cannot  serve  as  a reason  for 
denying  the  existence  of  a previous  inflammation  where  the  accidental  produc- 
tion was  originally  formed.  Besides  it  is  probable  that  at  a certain  period  the 
liver  would  have  been  found  more  or  less  changed  around  the  abscess;  but  it 
had  returned  to  its  normal  state,  according  as  a membrane,  becoming  organised 
around  the  pus,  had  gone  on  to  separate  it  more  completely  from  the  hepatic 
parenchyma,  in  which  it  remained  as  a foreign  body.  In  this  state  of  things, 
the  existence  of  an  abscess  in  the  liver  may  be  easily  conceived,  without  any 
disturbance  occurring  either  with  respect  to  the  texture  or  the  functions  of  this 
organ  : this  is  what  unquestionably  happens  with  respect  to  the  encephalon  : 
observation  has  proved  the  existence  of  encysted  abscesses  in  the  brain  of 
individuals  who,  for  a longer  or  shorter  time  before,  had  had  all  the  signs  of  an 
acute  encephalitis.  The  symptoms  of  the  latter  had  disappeared,  and  the  dis- 
ease might  have  been  considered  as  completely  cured  ; this  cure,  however,  was 
only  provisional  in  some  degree,  until  a new  process  of  inflammation  was  set 
up  around  the  abscess.  Thus,  also,  we  may  readily  conceive  how  a foreign 
body  might  remain  for  a long  time  in  the  brain,  without  manifesting  its  presence 
by  any  symptom,  and  then  all  at  once  indicate  its  existence  by  different  signs  of 
encephalitis  or  cerebral  hemorrhage. 

In  the  individual  whose  case  gave  rise  to  these  reflections  there  was  no 
characteristic  sign  of  any  chronic  affection  of  the  liver.  But,  if  we  go  back  to 
examine  the  other  periods  of  his  disease,  we  shall  find  that,  when  he  commenced 
no  longer  to  enjoy  his  habitual  health,  he  had  jaundice  of  considerable  duration. 
At  no  period,  moreover,  were  the  inflammation  of  the  liver,  and  the  suppura- 
tion in  which  it  terminated,  indicated  by  any  pain.  This  is  again  less  surprising 
in  this  case,  where  the  disease  followed  an  essentially  chronic  course,  than  in 
other  well-attested  cases  wherein  the  course  of  the  disease  was  acute. 

If  it  be  true  that  pain  occurs  in  the  majority  of  acute  inflammations,  it  must 
also  be  acknowledged  that  in  none  is  it  a necessary  condition  of  their  existence. 
Are  there  not  cases  of  pleuritis  and  peritonitis  unaccompanied  with  pain  ? 


DISEASES  OF  THE  ABDOMEN. 


371 


Case  20. — Abscess  of  the  liver  opening  into  the  peritoneum — Increased  size  of  the  live r — 
Jaundice — Pain  in  the  right  shoulder — Chronic  gastritis  at  the  onset. 

A tailor,  fifty  years  of  age,  who  had  had  repeated  attacks  of  syphilis,  which 
were  treated  with  mercury  given  internally,  and  in  the  form  of  friction,  since 
his  forty-ninth  year,  after  a syphilitic  affection,  for  which  he  had  taken  sarsa- 
parilla and  Van  Swieten’s  liquor,  began  to  complain  of  occasional  pains  in  the 
epigastrium.  In  their  abrupt  appearance  as  well  as  in  their  sudden  cessation, 
in  their  nature  and  intensity  also,  they  bore  considerable  resemblance  to  what 
is  commonly  called  cramp  of  the  stomach.  During  the  intermission  the  appetite 
was  preserved,  and  the  health  seemed  to  be  very  good.  Bv  degrees,  however, 
he  lost  flesh  and  strength  ; these  gastric  pains,  which  were  temporary,  but  very 
acute,  were  succeeded  by  a dull  pain,  or  rather  by  an  habitual  sensation  of 
weight ; the  appetite  became  irregular,  and  was  then  lost  altogether.  Such 
were  the  symptoms  which  existed  for  eighteen  months  ; the  patient  still  attended 
to  his  usual  business.  At  the  end  of  this  time  the  conjunctivae  and  skin  began 
to  present  a yellow  tint,  which  became  more  and  more  marked,  without  any 
pain  being  felt  in  the  region  of  the  liver.  But  some  time  after  the  appearance 
of  the  jaundice  a troublesome  and  continual  pain  was  felt  towards  the  right 
shoulder ; it  continued  to  be  felt  more  or  less  from  that  time. 

When  we  saw  the  patient  all  the  cutaneous  surface  was  of  a well-marked 
yellow  tint.  The  pain  in  the  right  shoulder  was  still  felt.  In  the  right  hypo- 
chondrium  the  liver  was  felt,  which  descended  three  fingers’  breadth  below  the 
edge  of  the  ribs  : it  was  pressed  without  seeming  to  be  painful.  The  affection 
of  the  stomach  was  characterised  by  a total  distaste  for  every  kind  of  food,  by 
an  habitual  sensation  of  weight  in  the  epigastrium,  vomiting  at  intervals,  a 
sensation  of  burning  heat  occasionally  felt  along  the  oesophagus,  which  seemed 
to  commence  at  the  cardiac  orifice.  The  tongue  was  habitually  covered  with 
a whitish  coat,  without  any  redness  of  its  edges  ; the  stools  were  scanty.  There 
was  some  fever  every  night. 

One  day  very  acute  pains  were  felt  in  the  right  hypochondrium,  and  the  day 
all  over  the  entire  abdomen.  At  the  same  time  there  was  vomiting,  tension  of 
the  abdomen,  which  could  not  be  pressed  in  any  part  without  exasperating  the 
pain  ; he  could  lie  only  on  his  back.  The  pulse  was  weak  and  irregular  ; the 
skin  became  cold  ; and  death  supervened  three  days  after  the  commencement 
of  these  pains. 

Post-mortem.  — Sero-purulent  effusion  into  the  peritoneum;  liver  hyper- 
trophied. On  raising  it  we  observed  a little  to  the  right  of  the  gall-bladder,  on 
the  lower  surface  of  its  right  lobe,  an  opening  in  its  substance,  through  which 
the  index  finger  might  be  readily  introduced  : this  opening  led  into  a cavity  full 
of  pus,  the  parietes  of  which  were  formed  of  the  parenchyma  of  the  liver ; 
inferiorly  this  parenchyma  formed  but  a very  thin  floor,  which  separated  the 
cavity  full  of  pus  in  the  liver  from  the  peritoneal  cavity.  It  was  this  thin 
lamina  of  the  hepatic  tissue  which  gave  way,  and  allowed  the  pus  formed  in 
the  liver  to  escape  into  the  peritoneum,  whence  arose  acute  inflammation  of 
this  membrane. 

There  were  two  or  three  red  spots  on  the  gastric  mucous  membrane,  over 
the  great  cul-de-sac,  each  being  about  the  size  of  a two-franc  piece.  In  some 
parts  it  was  so  soft  as  to  resemble  liquid  mucus  deposited  on  the  subjacent 
cellular  tissue.  In  the  pyloric  portion,  on  the  contrary,  the  mucous  membrane 
of  the  stomach  was  thickened,  hypertrophied,  and  of  a brownish  colour  : this 
same  colour  was  found  in  the  two  first  portions  of  the  duodenum. 

The  stomach  was  the  first  organ  which  appeared  to  be  affected  in  this  indi- 
vidual. It  is  impossible  to  say  at  what  period  the  affection  of  the  liver  com- 
menced ; it  is  probable  that  the  inflammation  of  the  stomach  extended  gradually 
to  the  biliary  apparatus  ; we  were  not  apprised  of  the  existence  of  any  affection 


372 


ANDRAL’S  MEDICAL  CLINIC. 


of  the  latter  till  the  jaundice  appeared,  which,  instead  of  being  merely  of  a 
temporary  duration,  as  in  the  subject  of  the  preceding  case,  continued,  on  the 
contrary,  till  the  death  of  the  patient.  Except,  however,  a slight  increase  in 
the  size  of  the  liver,  which  was  observed  here,  and  not  in  the  preceding  case, 
the  state  of  this  organ  was  the  same  in  both.  In  both  the  abscess  was  situate 
much  nearer  the  concave  than  the  convex  surface  of  the  organ  ; only  in  the  preced- 
ing case  it  occupied  the  left  lobe,  and  in  this  case  the  right  lobe. 

This  is  the  first  case  in  which  we  find,  among  the  morbid  phenomena  which 
manifest  themselves  during  the  progress  of  a disease  of  the  liver,  the  pain  in 
the  right  shoulder.  Neither  has  M.  Louis  met  it  in  any  of  the  five  cases  of 
abscess  detailed  by  him.  From  this  it  must  certainly  be  inferred  that  this  pain 
is  much  less  frequently  met  in  the  different  affections  of  the  liver  than  it  has 
been  stated. 

The  different  cases  of  abscess  of  the  liver  which  have  been  now  cited  have 
pointed  out  to  us  the  principal  varieties  which  these  abscesses  may  present; 
1st,  in  the  pathological  anatomy  ; 2dly,  in  their  causes  ; 3dly,  in  their  compli- 
cations; 4thly,  in  their  progress;  5thly,  in  their  symptoms;  6thly,  in  their 
modes  of  termination.  We  have  spoken  elsewhere  of  those  purulent  collections 
sometimes  found  in  the  hepatic  parenchyma,  and  which  seem  to  have  been 
deposited  rather  than  formed  therein.  These  purulent  collections  usually  coin- 
cide with  other  collections  found  in  different  organs,  and  in  the  great  majority 
of  cases  they  appear  to  be  connected  with  phlebitis. 

We  shall  now  cite  some  cases  wherein,  instead  of  pus,  another  species  of 
•accidental  production  was  formed  in  the  hepatic  parenchyma,  the  two  principal 
varieties  of  which  have  been  designated  scirrhous  and  encephaloid  tissue. 
Having  already  expressed  our  opinion  on  the  origin  and  nature  of  these  produc- 
tions, and  as  we  propose  to  recur  to  them  more  in  detail  in  another  work  (Patho- 
logical Jlnotomy ),  we  shall  not  here  deviate  from  the  language  generally  re- 
ceived ; we  shall  retain  provisionally  terms  which  seem  to  us  neither  correct 
nor  sufficient,  the  use  of  which,  however,  custom  has  consecrated  ; and,  suppos- 
ing the  anatomical  nature  of  cancer  of  the  liver  already  known,  we  shall  in  the 
following  cases  endeavour  to  point  out  its  symptoms  and  progress.  These  cases 
will  show  how  variable  are  the  signs  which  indicate  cancerous  affections  of  the  liver. 
Thus,  with  respectjo  the  symptoms,  there  are  many  shades  between  such  of 
those  affections  wherein  there  is  at  one  and  the  same  time  a tumour  in  the  right 
hypochondrium,  pain  in  this  same  part,  jaundice,  ascites,  anasarca,  and  those 
where  none  of  these  morbid  phenomena  are  observed,  and  where  \he  post-mortem 
examination  alone  discovers  the  disease  of  the  liver.  With  respect  to  their  course, 
there  are  some  of  these  affections  which  really  resemble  acute  diseases,  which 
are  developed,  and  terminate  fatally  in  a very  short  space  of  time  : there  are 
others  which  continue  for  a great  number  of  years,  without  producing  any  very 
serious  symptoms  for  a considerable  time.  We  shall  also  see  that,  as  well  as 
the  other  diseases  of  the  liver  already  mentioned,  cancer  of  this  organ  is  most 
frequently  accompanied  during  life  by  gastro-intestinal  symptoms;  and  that 
frequently,  though  not  always,  traces  of  chronic  inflammation  are  found  in  the 
digestive  tube,  and  particularly  in  the  stomach.  We  shall  now  cite  a case  of 
cancer  of  the  liver  remarkable  for  its  rapid  course. 

SECTION  II. 

CASES  OF  CANCER  OF  THE  LIVER. 

Case  21. — Cancerous  tumour  of  the  liver  and  gastro-hepatic  epiploon,  which  terminated  in 
death  three  weeks  after  the  first  appearance  of  the  symptoms — Jaundice — Healthy  state  of 
the  digestive  tube. 

A foreign  merchant,  about  forty-five  years  of  age,  had  been  several  times 


DISEASES  OF  THE  ABDOMEN. 


373 


attacked  with  intermittent  fevers ; however,  he  enjoyed  good  health  since  the 
fortieth  year  of  his  age.  During  the  month  of  April  he  felt  some  slight  pains 
immediately  beneath  the  cartilaginous  edge  of  the  false  ribs  of  the  right  side  ; 
towards  the  end  of  the  month  jaundice  appeared  ; he  then  entered  the  Charite. 
When  we  saw  him  he  had  no  fever  ; his  appetite  was  very  good ; the  digestive 
functions  seemed  to  be  intact,  only  the  stools  were  devoid  of  the  natural 
colour;  the  urine  was  of  an  orange-red  tint ; the  right  hypochondrium  was 
soft  and  free  from  pain.  (Whey,  with  acetate  of  potash  ; pills  of  calomel  and 
soap.) 

May  2d. — The  pains  in  the  right  hypochondrium  reappeared;  on  the  follow- 
ing days  they  continued,  fever  set  in,  the  hypochondrium  became  tense,  as  if  it 
were  occupied  by  the  tumefied  liver.  (Leeches  over  the  hypochondrium.) 

May  9th. — We  began  to  feel,  immediately  beneath  the  edge  of  the  ribs,  to  the 
right  of  the  epigastrium,  a round  immoveable  tumour,  which  was  very  painful 
on  pressure.  (Narcotic  cataplasms.) 

From  the  9th  to  the  15th  the  tumour  became  very  large  ; it  was  now  visible, 
and  beside  it  several  other  knobby,  uneven,  and  painful  tumours  soon  appeared. 

From  the  15th  to  the  20th,  these  tumours  extended  behind  the  cartilages  of 
the  ribs,  and  raised  them  considerably  ; at  the  same  time  the  patient  began  to  vomit 
his  drinks,  three  or  four  hours  after  taking  them  ; the  fever  was  continued 
with  a violent  exacerbation  every  evening,  during  which  the  pains  of  the  hy- 
pochondrium became  very  acute  ; the  patient  wasted  away  with  frightful  rapidity. 
He  died  on  the  21st. 

The  liver  was  large,  and  passed  the  breadth  of  four  fingers  beyond  the  edge 
of  the  ribs.  From  its  convex  surface  several  tumours  projected,  formed  of  a 
mixture  of  accidental  productions,  usually  designated  by  the  name  of  scirrhous, 
encephaloid,  and  tuberculous  tissues.  These  tumours  extended  a considerable 
way  into  the  substance  of  the  viseus.  Between  them  the  tissue  of  the  liver 
did  not  appear  changed.  Similar  tumours  surrounded  and  compressed  the 
ductus  hepaticus  and  choledochus,  as  well  as  the  pyloric  extremity  of  the  stomach. 

It  is  possible  that  the  tumours  of  the  liver  and  gastro-hepatic  epiploon  now 
described  had  existed  for  several  years  in  this  individual,  and  that  their  first 
origin  was  connected  with  the  repeated  intermittent  fevers  to  which  he  had 
been  subject.  The  existence  of  such  tumours,  still  small,  few  in  number,  and 
in  a state  of  crudity,  is  not  incompatible  with  a tolerably  good  state  of  health. 
But  what  we  wish  principally  to  point  out  here  is,  the  extreme  rapidity  of  their  in- 
crease, and  the  rapidly  fatal  symptoms  to  which  this  rapid  increase  gave  rise.  The 
febrile  disturbance  was  here  similar  to  that  which  accompanies  acute  inflamma- 
tion of  the  digestive  tube  ; the  severity  of  the  pain  was  directly  proportioned  to 
the  acute  development  of  the  cancer.  It  was  also  remarkable  how  rapidly  the 
patient  wasted  away.  In  this  rapid  and  very  great  alteration  of  nutrition,  how 
very  much  must  not  the  blood  and  nervous  system  also  have  been  modified  ! 
Thence  probably  the  extinction  of  life. 

This  case  may  be  compared  to  those  cited  in  a preceding  part  of  this  work, 
which  refer  to  the  acute  development  of  tubercles  within  the  pulmonary  paren- 
chyma. 

We  shall  not  omit  to  notice  here  the  very  healthy  state  of  the  tissue  of  the 
liver  around  the  cancerous  masses.  Is  it  not,  however,  under  such  circum- 
stances that  we  should  have  found  traces  of  inflammation? 

We  submit  this  fact  to  the  consideration  of  those  who  refer  the  cause  of  every 
accidental  production  to  this  latter  circumstance. 

The  jaundice,  which  existed  during  the  entire  time  the  patient  stayed  in  the 
hospital,  might  be  connected  with  the  alteration  of  the  hepatic  parenchyma  ; but, 
independently  of  that,  we  here  find  another  circumstance  to  account  for  it,  a 
cause  of  obstruction  altogether  mechanical  in  the  tumours,  the  existence  of 
22 


374 


ANDRAL’S  MEDICAL  CLINIC. 


which  was  proved  by  \he  post-mortem  examination,  around  the  ductus  hepaticus, 
and  choledochus  ; in  this  case,  also,  the  nature  of  the  stools  announced  before 
the  patient’s  death  that  the  bile  no  longer  entered  the  duodenum. 

The  vomiting,  which  came  on  towards  the  close,  was  not  accounted  for  by  a 
morbid  state  of  the  digestive  passages  ; the  stomach,  duodenum,  and  the  remain- 
der of  the  digestive  tube,  were  all  found  exempt  from  every  species  of  lesion. 
Might  not  this  vomiting  be  referred  to  the  compression  on  the  pylorus  by  the 
tumours  which  surrounded  it?  This  fact  further  proves  that  there  may  be 
fever  and  the  patient  may  die,  without  there  being  any  gastro-intestinal  in- 
flammation. 

Case  22. — Cancerous  tumours  in  the  liver,  and  also  in  the  stomach,  in  the  lymphatic  glands 

in  front  of  the  spine,  and  around  the  uterus — Tumour  and  pain  in  the  right  hypochondrium — 

J aundice — Ascites. 

A washerwoman  fifty-three  years  of  age  had  been  ill  for  about  seven  months, 
when  she  entered  the  Charite.  She  had  at  first  all  the  symptoms  of  acute  rheu- 
matism ; pain  in  the  lumbar  region  ; painful  swelling  of  several  joints  ; fever. 
She  then  entered  the  Hotel  Dieu,  where  she  was  bled  several  times.  When 
she  left  it  (about  three  weeks  after  her  admission)  she  was  free  from  the»pains 
of  the  joints  and  those  of  the  lumbar  region.  But  presently  new  symptoms 
supervened  ; she  began  to  feel  a dull  pain  on  the  level  of  the  last  ribs  of  the 
right  side  ; at  the  same  time  the  digestive  functions,  which  till  then  were  good, 
became  deranged  ; the  mouth  was  constantly  dry,  and  often  bitter ; immediately 
after  taking  food  she  was  troubled  with  acid  eructations  ; her  food  was  from  time 
to  time  vomited.  No  pain  was  felt  in  the  epigastrium.  These  different  symp- 
toms appeared  and  continued  during  the  six  months  preceding  her  admission 
into  the  Charite.  When  we  saw  her,  her  state  was  as  follows  : — 

Emaciation  was  considerable:  the  conjunctive  were  yellow,  as  well  as  the 
entire  skin.  This  jaundice  had  been  in  existence  only  for  the  last  six  weeks. 
Evident  fluctuation  in  the  abdomen  ; she  stated  that  her  abdomen  began  to  swell 
nearly  at  the  same  time  that  she  became  yellow  ; the  extremities  had  never  been 
infiltrated.  The  right  hypochondrium  and  right  part  of  the  epigastrium  were 
occupied  by  a tumour,  the  form  of  which  we  could  not  ascertain  satisfactorily, 
nor  could  we  circumscribe  its  limits  in  consequence  of  the  fluid  effused  into  the 
peritoneum,  some  of  which  was  interposed  between  the  tumour  and  the  abdominal 
parietes.  This  tumour  was  in  other  respects  very  distinct ; the  patient  felt 
rather  acute  pains  in  it,  but  only  at  intervals ; these  pains,  however,  did  not 
come  on  in  a lancinating  form.  Pressure  was  painful  over  all  the  right  hypo- 
chondrium ; everywhere  else  the  abdomen  was  free  from  pain.  The  tongue 
was  covered  with  a thick  yellowish  coat.  There  was  complete  loss  of  appe- 
tite for  the  last  five  months.  The  mouth  was  usually  dry,  without  there  being 
much  thirst ; the  introduction  of  food,  and  even  of  drink,  into  the  stomach, 
was  followed  by  a sensation  of  weight  in  the  epigastrium.  This  sensation  was 
changed  into  that  of  a burning  heat  when  the  patient  drank  merely  a single 
spoonful  of  wine.  Vomiting  had  not  now  occurred  for  a considerable  time; 
but  she  often  voided,  as  if  by  regurgitation,  a certain  quantity  of  what  she  called 
glairy  mucus.  There  was  usually  obstinate  constipation.  The  urine  was  a 
mahogany-red  colour,  small  in  quantity,  and  was  scalding  hot  when  being 
passed.  Pulse  not  frequent,  remarkably  small ; skin  dry,  and  not  hot;  but 
every  evening,  for  the  last  two  or  three  months,  the  patient  felt  herself  burning 
hot. 

She  died  six  days  after  her  admission.  During  this  short  space  of  time  all 
the  drinks  which  she  took  were  rejected  by  vomiting  ; she  had  frequent  fainting 
fits  ; the  two  thighs  were  infiltrated  a little  ; the  urine  presented  a very  copious 


DISEASES  OF  THE  ABDOMEN.  375 

rose-coloured  deposit ; the  pulse  gradually  ceased  to  be  felt ; after  her  last 
effort  to  vomit  she  fainted,  and  expired. 

Post-mortem.  The  liver  passed  several  fingers’  breadth  beyond  the  edge  of 
the  ribs.  It  was  knobby,  marked  with  white  irregular  spots,  in  the  centre  of 
several  of  which  there  was  a depression.  These  spots  corresponded  to  so  many 
cancerous  masses  which  existed  in  a great  number  within  the  liver.  Three 
substances,  of  different  appearances,  formed  them  : one  of  a yellowish-white 
colour,  and  friable ; the  other  greyish ; the  third  of  a dull  white,  traversed  by 
several  reddish  lines.  Around  these  morbid  products,  to  the  extent  of  some 
lines,  the  tissue  of  the  liver  was  softer,  more  friable,  and  redder  than  else- 
where. 

The  bile  ducts,  at  their  exit  from  the  liver,  were  surrounded  by  large  cancerous 
masses,  which  might  contribute  to  obliterate  their  cavity. 

Stomach.  Not  far  from  the  pylorus,  which  was  free,  the  mucous  membrane 
was  raised  by  an  irregularly  rounded  tumour,  the  size  of  a large  chestnut,  formed 
of  a tissue  of  a dull  white  colour ; beneath  it  the  muscular  membrane  was 
healthy.  The  portion  of  mucous  membrane  covering  it  closely  adhered  to  it ; 
it  was  manifestly  thickened,  and  of  a slate  colour.  The  stomach  was  filled 
with  a matter  resembling  soot. 

In  front  of  the  vertebral  column  other  cancerous  masses  were  observed,  by 
several  of  which  the  aorta  was  raised. 

Five  or  six  small  tumours,  each  the  size  of  a nut,  consisting  of  a dull  white 
tissue,  and  without  any  appearance  of  fibres,  were  found  between  the  proper 
tissue  of  the  body  of  the  uterus  and  the  peritoneum  covering  it. 

The  progress  of  this  cancer  of  the  liver  was  also  rather  rapid  ; the  patient  died 
six  months  after  the  appearance  of  the  first  symptoms  which  indicated  the  ex- 
istence of  any  affection  of  the  liver  and  stomach.  It  would  be  difficult  to  say 
which  of  the  two  affections  preceded  the  other:  it  would  appear  that  they 
commenced  nearly  at  the  same  time.  The  disease  of  the  liver  here  is  ex- 
tremely well  marked  ; there  was  pain  and  swelling  of  the  right  hypochondrium, 
jaundice,  and  ascites  ; pain  was  one  of  the  first  symptoms  which  appeared.  It 
was  never  as  acute  as  in  the  subject  of  the  preceding  case  ; nor  was  it  lan- 
cinating, as  all  the  pains  of  cancerous  affections  are  stated  to  be.  With  respect 
to  the  jaundice  we  here  again  find  it  to  coincide  with  the  existence  of  tumours 
which,  developed  around  the  bile  ducts,  might  compress  or  irritate  them. 

We  should  not  forget  to  remark  that  in  this  individual,  wherever  the  function 
of  nutrition  deviated  from  its  normal  type,  accidental  products  of  the  same 
nature  were  developed.  Thus  nothing  could  be  more  like  the  matter  found  in 
the  liver,  than  that  which  was  deposited  in  the  substance  of  the  parietes  of  the 
stomach,  around  the  body  of  the  uterus,  and  before  the  vertebral  column;  this 
was  principally  remarked  around  the  uterus,  where  fibrous  tumours  are  gene- 
rally found. 

Case  23 — Cancer  of  the  liver — Chronic  gastro-duodenitis — Tumour  in  the  right  hypochon- 
drium— Jaundice. 

A public  writer,  thirty-seven  years  of  age,  enjoyed  a good  state  of  health, 
when  one  day,  after  having  been  exposed  to  a current  of  cold  air,  whilst  he  was 
in  a state  of  perspiration,  he  was  seized  with  the  different  symptoms  of  cholera 
morbus  ; profuse  evacuations,  upwards  and  downwards,  sudden  prostration, 
etc.  These  symptoms  disappeared  after  a few  days  ; but  from  this  moment  he 
felt  a difficulty  in  digesting  his  food  hitherto  unknown  to  him  ; the  presence  of 
food  excited  in  him  a feeling  of  fulness  and  abdominal  tension  ; he  had  some- 
times also  some  diarrhoea.  Three  years  passed  on  in  this  way,  after  which  he 
became  yellow.  He  then  entered  the  Charite, 


376 


ANDRAL’S  MEDICAL  CLINIC. 


His  emaciation  was  now  considerable  ; all  his  skin  was  of  a jaundiced  colour, 
and  was  so  for  the  last  seven  or  eight  months.  We  felt  very  distinctly  in  the 
right  hypochondrium  a body  with  an  uneven  surface,  which  terminated  in  a thin 
edge  a little  above  the  level  of  the  umbilicus,  and  which,  on  the  left,  extended 
into  the  epigastrium  a little  beyond  the  xiphoid  cartilage.  The  patient  did  not 
perceive  the  presence  of  this  tumour;  he  had  never  felt  the  least  pain  in  it,  nor 
did  pressure  produce  any  in  it.  One  could  hardly  hesitate  to  admit  that  this 
tumour  was  the  liver  increased  in  size  ; but  what  was  the  nature  of  the  affection  ? 
was  it  merely  hypertrophied,  indurated,  or  softened  ? were  accidental  productions 
developed  in  it?  This  it  was  impossible  to  determine.  There  neither  was  at 
present,  nor  had  there  been,  any  dropsy.  For  a long  time  back  the  patient  had 
lost  all  appetite  ; when  he  took  the  least  aliment,  solid  or  liquid  into  his  stomach, 
he  experienced  a general  indisposition,  and  at  the  same  time  a feeling  of  swell- 
ing at  the  epigastrium,  but  never  any  real  pain.  A great  quantity  of  gas  was 
voided  by  the  mouth  ; he  had  scarcely  vomited  two  or  three  times  when  his 
digestion  began  to  be  deranged.  He  complained  of  often  feeling  pulsations  of 
the  heart,  sometimes  preceded  by  rather  an  acute  pain  in  the  praecordial  region. 
He  also  experienced  from  time  to  time  very  distressing  headachs,  disturbances 
of  vision,  formication  in  the  hands  and  feet,  tempqrary  chronic  contractions  of 
the  different  muscles.  He  said  he  had  no  longer  any  physical  or  moral  strength, 
and  that  he  was  continually  exhausted,  as  a person  who  had  exercised  himself 
beyond  his  strength.  For  several  months  back  the  frequent  diarrhoeas  to  which 
he  was  subject  were  succeeded  by  an  obstinate  constipation  ; the  latter  set  in 
nearly  at  the  same  time  that  the  jaundice  appeared.  The  colour  of  the  stools 
was  not  ascertained,  nor  that  of  the  urine.  The  pulse  was  uniformly  frequent ; 
the  palm  of  the  hands  burning  hot ; skin  always  dry;  and  the  patient  com- 
plained of  a very  troublesome  itching. 

Vichy  water  was  given  him,  which  had  no  other  effect  than  that  of  lighting  up 
fever,  and  of  exciting  pains  in  the  epigastrium,  which  the  patient  had  not  pre- 
viously felt.  But  this  ceased  as  soon  as  the  use  of  the  mineral  water  was  given 
up.  This  patient  remained  for  about  two  months  in  the  hospital,  gradually 
becoming  weaker.  On  a sudden,  symptoms  of  pleuro-pneumonia  of  the  right 
side  set  in,  which  were  treated  by  revulsives  applied  to  the  chest  and  lower  ex- 
tremities ; this  proved  unavailing,  and  he  died.  • 

Post-mortem. — Greenish  yellow  tint  of  the  entire  skin  mr  some  red  spots  resem- 
bling ecchymosis  on  the  legs.  Extreme  marasmus. 

The  liver  formed  in  the  abdomen  a large  tumour,  which  occupied  the  right 
hypochondrium,  the  epigastrium,  left  hypochondrium,  and  descended  on  a line 
with  the  umbilicus.  It  presented  a smooth  and  even  surface.  Externally  it  was 
remarkable  for  its  brownish-green  colour,  and  presented  no  other  alteration.  But 
we  had  scarcely  made  an  incision  into  it  when  we  found  in  it  a number  of 
whitish  masses,  hard  or  soft,  reduced  to  a pap  ; several  streaked  with  reddish 
lines,  which  left  between  them  certain  areolae  varying  in  form  and  size,  others 
having  blood  effused  into  the  midst  of  them.  There  was  bile  in  the  gall- 
bladder. 

The  internal  surface  of  the  stomach  presented  through  its  entire  extent  a slate 
colour,  the  seat  of  which  was  in  the  mucous  membrane;  this  membrane  was 
thickened,  indurated,  uneven  at  its  surface.  The  same  colour  was  continued 
into  the  duodenum,  the  follicles  of  which  were  moreover  observed  to  be  very 
much  enlarged.  Over  the  rest  of  the  digestive  tube  nothing  was  observed  but 
large  oval  patches,  with  black  points,  towards  the  termination  of  the  ileum 
(Peyer’s  glands),  and  a brownish  colour  of  the  caecum. 

The  mesenteric  glands,  principally  those  corresponding  to  the  caecum,  were 
large,  and  of  a pale  red  colour  internally. 

False  membranes  of  recent  formation  connected  a considerable  portion  of  the 


DISEASES  OF  THE  ABDOMEN. 


377 


pleuree  costalis  and  pulmonalis  of  the  right  side.  The  lower  lobe  of  the  lung 
of  this  side  was  in  a state  of  red  hepatisation.  No  lesion  of  the  heart  or  of  its 
appendages.  In  the  encephalon  considerable  serous  infiltration  of  the  subarach- 
noid cellular  tissue  of  the  convexity  of  the  hemispheres. 

We  here  find  one  symptom  less  than  in  the  preceding  eases,  namely,  the 
pain.  This  is  a well-marked  case,  which  proves  that  cancerous  masses  may 
be  developed  in  great  numbers  in  the  liver,  may  exist  there,  both  in  their  crude 
and  softened  state,  without  this  organ  becoming  the  seat  of  any  pain.  If  we 
inquire  why  in  this  case  the  affection  of  the  liver  was  completely  free  from 
pain,  whilst  in  those  already  cited  it  was  accompanied  with  pains  more  or  les& 
acute,  of  a lancinating  character  or  otherwise,  we  shall  not  find  any  reason  for 
this  difference  either  in  the  number  or  texture  of  the  accidental  productions,  or 
in  the  state  of  the  tissue  of  the  liver  around  them.  We  may  remark  here, 
however,  that  none  of  these  productions  was  visible  externally ; that  they  were 
all  deep  seated  in  the  organ,  and  remote  from  the  peritoneum. 

The  onset  of  the  disease  is  another  remarkable  circumstance  in  this  case* 
It  was  after  cholera  morbus  that  different  disturbances  of  digestion  appeared, 
which  were  proved  by  the  post-mortem  to  be  the  result  of  a chronic  gastro- 
enterite.  At  the  time  of  the  patient’s  death  there  had  been  no  diarrhoea  for  a 
long  time,  and  the  symptoms  indicated  that  intestinal  inflammation,  properly 
so  called,  no  longer  existed.  We  should  consider  also  the  species  of  lesion 
found  in  the  intestine ; mere  enlargement  of  Peyer’s  glands,  and  brown  colour* 
ing  of  the  caecum.  These  two  lesions  remained  as  traces  of  an  inflammation 
which  no  longer  existed  ; there  was  besides  a state  of  hypertrophy  of  the  glands 
of  the  mesentery,  which  probably  was  also  the  result  of  the  previous  enterite. 

With  respect  to  the  stomach,  the  chronic  inflammation  having  extended  to 
the  duodenum,  of  which  it  was  the  seat,  indicated  its  existence  by  two  orders  of 
symptoms : the  one,  local,  were  those  to  which  we  have  already  several  times 
called  attention ; the  epigastric  pain  existed  but  temporarily,  and  in  a form  in 
some  measure  accidental  under  the  influence  of  a stimulating  treatment.  Other 
symptoms  were  general,  and  the  result  of  irritations  sympathetic  of  the  affection 
of  the  stomach  : we  may  remark  principally  that  general  indisposition,  that 
marked  sinking  ( brisement ) of  which  the  patient  complained,  the  formication, 
headach,  muscular  contractions,  the  beating  of  the  heart  which  he  experienced, 
and  the  momentary  pains  which  he  felt  in  different  parts  of  the  body.  How 
many  times  have  such  symptoms  been  called  nervous,  because  the  local  lesion 
of  which  they  were  the  sympathetic  effect  was  indicated  by  symptoms  so  little* 
marked  that  it  easily  escaped  investigation  ? 

In  this  patient  also  the  disease  of  the  liver  appears  to  have  been  consecutive 
on  the  gastro-intestinal  affection  ; the  jaundice  came  on  a considerable  time 
after  the  digestive  functions  began  to  be  deranged.  There  was  not  here,  any 
more  than  in  the  preceding,  cases,  any  obstacle  to  the  course  of  the  bile.  It 
may  further  be  remarked  that  in  this  case  the  disease  of  the  liver  was  found  to 
be  connected  with  a chronic  duodenitis ; at  least  we  are  disposed  to  consider  as 
such,  or  at  least  as  vestiges  of  it,  the  slate  colour  of  the  mucous  membrane  of 
this  intestine,  and  the  hypertrophy  of  its  follicles. 

Case  24.— -Cancerous  masses  developed  in  the  liver — Diminution  of  its  size — Chronic  gastritis 
(Ulceration,  with  scirrhous  induration  of  the  submucous  tissues) — Jaundice— Ascites — Ab- 
sence of  pain. 

A man,  sixty-six  years  of  age,  who  had  been  a soldier  for  18  years,  had  had 
an  intermittent  fever  of  a quartan  type,  which  lasted  for  nine  months.  How- 
ever, after  recovering  from  this  fever,  he  continued  to  enjoy  very  good  health. 
About  a year  before  his  entering  the  Charite  he  got  a fall,  in  which  the  epigas- 
32* 


378 


ANDltAL’S  MEDICAL  CLINIC. 


trium  was  very  much  contused  by  a hard  body.  A little  time  after  this  fall  he 
had  profuse  hematemesis,  and  since  then,  without  ever  experiencing  any  epi- 
gastric pain,  he  lost  appetite,  had  frequent  purging,  and  hecame  yellow.  About 
two  months  before  entering  the  hospital  the  abdomen  began  to  swell,  without 
pain  having  ever  been  felt  in  any  part  of  that  cavity. 

State  of  the  patient  at  the  time  of  his  admission  : — Jaundice  over  the  entire 
body  well  marked  ; emaciation  ; evident  fluctuation  in  the  abdomen,  which  was 
very  much  enlarged,  free  from  pain  in  every  part,  nor  could  any  tumour  be 
detected  in  it.  Tongue  white,  without  any  redness  at  apex  or  edges  j no  thirst ; 
loss  of  appetite ; no  vomiting  at  any  period  ; three  or  four  liquid  stools  in  the 
twenty-four  hours,  for  several  months  back.  Faeces  were  yellow.  Pulse  a 
little  frequent,  without  any  heat  of  skin.  Urine  reddish,  depositing  a sediment. 
(Fumigation  with  juniper  baths;  frictions  on  the  extremities  with  camphorated 
alcohol  and  tincture  of  cantharides  ; diuretic  drinks.)  The  patient  gradually 
became  weaker,  and  died.  Towards  the  termination  the  diarrhoea  increased 
very  much,  and  fever  set  in.  No  pain  had  been  felt  in  any  part  of  the  abdo- 
men. The  ascites  went  on  increasing.  The  lower  extremities  became  a little 
infiltrated.  A little  before  death  the  patient,  who  previously  had  no  cough, 
expectorated  a considerable  quantity  of  greenish  puriform  sputa. 

Poxt-mortem. — Skin  yellow  ; effusion  of  a great  quantity  of  fluid  into  the 
peritoneum,  which,  however,  presented  no  trace  of  inflammation,  either  recent 
or  of  long  standing. 

The  liver  occupied  but  a small  space  behind  the  last  ribs  of  the  right  side: 
its  size  was  evidently  less  than  natural ; its  tissue  was  of  a greenish-brown 
colour.  In  its  interior  we  found  five  or  six  whitish  masses,  each  nearly  the 
size  of  a large  nut;  four  of  them  were  hard  and  streaked  with  some  reddish 
lines,  or  dotted  with  points  of  the  same  colour ; two  others  of  them  were  softened, 
and  in  one  of  the  latter  there  was  a little  blood  mixed  with  the  detritus  of  the 
mass.  None  of  them  projected,  nor  were  they  visible  on  the  exterior  of  the 
liver. 

There  was  a large  ulcer  on  the  inner  surface  of  the  stomach,  towards  the  great 
cul-de-sac,  as  large  as  a five-franc  piece.  Its  edges  were  formed  of  tumefied 
mucous  membrane.  At  the  bottom  of  it  the  submucous  cellular  tissue  was  at  first 
found  changed  into  a substance  of  a dull  white  colour,  several  lines  in  thickness. 
Beneath  it  was  the  muscular  membrane,  which  ever*y  where  presented  the  same 
appearance.  In  several  points,  and  principally  towards  the  circumference  of 
the  ulcer,  this  membrane  was  thicker  than  outside  the  ulcer.  There  it  was 
divided  into  fasciculi,  or  lobules,  by  white  fibro-cellular  intersections,  which  on 
the  one  hand  were  connected  with  the  submucous  cellular  tissue,  and  on  the 
other  hand  with  the  subperitoneal  cellular  tissue.  Near  the  centre  of  the  ulcer- 
ation the  muscular  membrane  was  not  so  perceptible  ; it  presented  itself  merely 
in  the  form  of  thinly-scattered  fasciculi,  separated  by  considerable  intervals 
occupied  solely  by  masses  of  white  cellular  tissue.  These  masses  seemed  to  be 
merely  an  enlargement  of  the  white  striae  of  the  circumference.  As  we  have 
explained  it  elsewhere,  according  as  the  cellular  tissue  forming  these  lines  and 
these  masses  became  developed,  the  muscular  tunic,  being  compressed,  partly 
disappeared.  In  other  parts,  where  the  homogeneous  white  tissue  became 
more  predominant,  the  muscular  tunic  actually  existed  merely  in  shreds,  in 
isolated  points  ; everywhere  else  no  trace  of  them  was  perceived.  Some  lym- 
phatic glands  enlarged,  and,  after  undergoing  the  white  (scirrhous)  induration, 
were  found  beneath  the  ulceration  just  described,  between  the  stomach  and 
spleen,  and  closely  united  these  two  organs  together.  The  mucous  membrane 
of  the  termination  of  the  ileum  presented  a bright  red  injection  ; that  of  the 
large  intestine  was  thickened,  and  of  a brownish-grey  colour.  The  inner  sur- 
face of  the  aorta,  of  the  costal  cartilages  and  dura  mater,  presented  a well-marked 
yellow  colour. 


DISEASES  OF  THE  ABDOMEN. 


379 


It  was  after  external  violence  that  the  affection  of  the  stomach  appeared  to 
have  come  on  in  this  individual ; and,  consecutively  to  this,  the  disease  of  the 
liver.  The  disease  commenced  by  a most  alarming  symptom,  hematemesis  ; 
and  whether  this  was  the  result  of  a rupture  of  a large  vessel,  occasioned  by 
the  fall  on  the  epigastrium,  or  whether  it  depended  on  mere  exhalation  of  the 
congested  capillaries,  this  vomiting  was  followed  by  disorganisation  of  both  the 
stomach  and  liver,  which  was  not  indicated  by  any  pain.  It  was  only  towards 
the  termination  of  the  disease,  when  the  power  of  nutrition  had  been  a consi- 
derable time  modified,  that  jaundice  and  ascites  came  on,  the  only  symptoms 
of  liver  disease.  Besides  the  cancerous  masses,  we  find,  in  order  to  account 
for  the  ascites,  that  diminution  in  the  size  of  the  liver,  which  in  some  of  the 
preceding  cases  we  have  frequently  seen,  coincide  with  collections  of  serum  in 
the  peritoneum.  With  respect  to  the  jaundice,  it  was  not  accounted  for  in  this 
case  by  the  existence  of  any  obstacle  in  the  bile  ducts  ; and  further,  we  are 
certain  from  the  nature  of  the  stools  that  the  bile  entered  the  duodenum  during 
life. 

Nor  should  we  forget  to  remark  how  severe  the  alteration  of  the  stomach 
was,  and  how  little  marked  were  the  symptoms  which  announced  it.  Distaste 
for  food,  and  nothing  more  ! 

Some  lympihatic  glands  were  enlarged  here  in  the  vicinity  of  the  ulceration 
of  the  stomach,  as  they  are  seen  frequently  enlarged  in  the  vicinity  of  acute  or 
chronic  inflammations  of  the  intestine. 

The  increase  of  the  diarrhoea  and  the  fever  during  the  last  few  days  seem  to 
us  to  be  owing  to  the  red  injection  of  the  termination  of  the  ileum  ; whilst  the 
state  of  the  large  intestine  accounts  for  the  old  purging.  Thus,  worn  out  by  a 
chronic  disease,  this  individual,  like  so  many  others,  died  of  acute  inflamma- 
tion. 


Case  25. — Caneer  of  the  liver;  similar  degeneration  of  the  stomach,  pancreas,  and  epiploon — 

Indolent  tumour  in  the  right  hypochondrium — Derangement  of  the  digestive  functions — 

Absence  of  jaundice  and  dropsy. 

A woman,  forty-three  years  of  age,  enjoyed  good  health  up  to  the  age  of 
forty.  She  then  ceased  to  menstruate,  and  nearly  at  the  same  time  her  diges- 
tion became  deranged,  without  her  experiencing  any  real  pain  in  the  epigas- 
trium. She  had  no  appetite  ; the  introduction  into  the  stomach  of  the  little 
food  which  she  took  was  followed  by  general  indisposition,  and  a feeling  of 
fulness  in  the  abdomen.  She  had  frequent  acid  eructations.  In  this  first 
period  of  her  disease  she  took  some  rhubarb,  then  some  quinquina  ; no  improve- 
ment followed  this  : she  then  took  some  quinquina  in  decoction,  without  any 
benefit.  She  was  then  attacked  with  vomiting,  which  afterwards  came  on  at 
intervals  more  or  less  remote.  The  matters  vomited  were  of  three  kinds  : 
sometimes  it  was  merely  the  food  which  she  had  taken  ; sometimes  a great 
quantity  of  mucus  ; sometimes  again  a brownish  liquid,  like  coffee-grounds. 

This  gastric  affection  was  of  three  years’  standing  when  we  first  saw  her  ; 
her  emaciation  and  debility  were  extreme  : the  face  had  a marked  straw-coloured 
tint ; there  was  no  trace  of  jaundice  in  any  other  part.  The  liver  evidently 
extended  two  or  three  fingers’  breadth  below  the  ribs  in  the  two  hypochondria 
and  epigastrium  ; the  sharp  edge  of  it  was  readily  traced.  The  patient  felt  no 
pain  in  any  point  of  the  chest  or'  abdomen,  nor  did  pressure  occasion  any. 
The  tongue  was  merely  pale ; frequent  acid  eructations  took  place,  and  almost 
every  day  for  some  time  she  vomited  the  matters  mentioned  above ; the  stools 
were  scanty,  brownish,  and  hard  ; pulse  small  and  frequent ; skin  hot  and  dry. 
(Demulcent  drinks  ; milk  and  water.) 

A few  days  after  the  patient’s  admission  twoblisters  were  applied  to  the  legs 


380 


ANDRAL’S  MEDICAL  CLINIC, 


they  occasioned  great  irritation  of  the  nervous  system.  On  the  day  after  she 
was  in  a state  of  great  agitation ; the  pain  she  felt  in  the  parts  to  which  the 
blisters  had  been  applied  forced  the  most  piercing  cries  from  her;  the  pulse, 
which  was  small  and  contracted,  had  become  very  frequent ; the  blisters  were 
covered  with  an  emollient  cataplasm.  In  the  course  of  the  day  this  nervous 
exaltation,  so  very  remarkable  in  the  exhausted  state  of  the  patient,  was  suc- 
ceeded by  extreme  sinking,  both  physical  and  moral.  In  the  evening  the  blis- 
tered surface  was  covered  with  a black  crust ; death  took  place  the  next 
morning. 

Post-mortem . Great  emaciation.  No  trace  of  jaundice,  nor  of  dropsy. 

Nothing  remarkable  in  the  brain  and  its  membranes.  Ventricles  empty. 

The  liver,  as  we  had  ascertained  during  life,  extended  as  far  as  the  left  hypo- 
chondrium,  and  went  three  fingers’  breadth  beyond  the  edge  of  the  ribs.  In 
the  right  flank  it  touched  the  crest  of  the  ileum.  The  stomach  was  completely 
covered  by  it.  Externally  it  was  of  a reddish  colour,  streaked  in  several  places 
by  a dirty  white  tint.  Where  this  latter  tint  existed  the  finger  felt  a manifest 
fluctuation.  It  corresponded  accordingly  with  large  cavities  filled  with  a sort 
of  pap,  the  colour  of  which  varied  from  a dirty  grey  to  a red.  In  whatever 
part  an  incision  was  made  into  the  liver,  similar  cavities  were  entered.  Seve- 
ral contained  a more  solid  matter,  which  again  might  be  readily  crumbled  by 
slight  pressure,  and  which  was  then  changed  into  a pap  similar  to  that  contained 
in  the  other  cavities.  Again  in  some  few  places  we  found  tumours  in  the  tissue 
of  the  liver,  the  size  of  a large  nut,  formed  of  a dull  which  substance,  streaked 
with  reddish  lines,  some  points  of  which  were  changed  into  a pulpy  liquid  of  a 
dirty  reddish-grey  colour.  The  gall-bladder  was  distended  with  a very  black 
and  very  thick  bile. 

The  liver  having  been  removed,  another  large  tumour  was  discovered,  limited 
above  by  the  stomach  inferiorly,  and  on  both  sides  by  the  three  portions  of  the 
duodenum.  It  consisted  of  apparently  inorganic  matter,  of  a dull  white  colour, 
hard  and  creaking  under  a knife.  On  its  left  side  nothing  was  found  but  a very 
small  vestige  of  the  pancreas.  Oh  including  this  gland  and  the  tumour  in  one 
and  the  same  cut,  the  healthy  tissue  of  the  pancreas  was  observed  to  disappear 
all  at  once,  and  to  be  succeeded  by  the  tissue  of  the  tumour.  On  the  inner 
surface  of  the  latter,  however,  some  scattered  granulations  of  the  gland  were  ob- 
served. 

The  tumour  just  described  was  continued  with  several  others  of  the  same 
nature,  which  surrounded  the  pyloric  extremity  of  the  stomach  and  the  commence- 
ment of  the  duodenum. 

To  the  extent  of  five  or  six  fingers’  breadth  on  this  side  of  the  pylorus  there 
was  nothing  found  in  the  place  of  the  different  coats  which  constitute  theparietes 
of  the  stomach  but  a homogeneous  white  and  hard  tissue.  Over  this  extent 
the  mucous  membrane  was  destroyed  ; at  the  bottom  of  the  ulcer  arising  from 
its  destruction  there  was  a whitish  pulpy  matter,  one  or  two  lines  thick. 
Lastly,  in  the  substance  of  the  great  epiploon,  immediately  below  the  trans- 
verse colon,  a tumour  was  developed,  as  large  as  an  ostrich’s  egg,  formed,  as 
that  circumscribed  by  the  duodenum,  of  a homogeneous,  hard,  and  dull  white 
substance. 

Is  it  not  a very  remarkable  circumstance  in  this  case  that,  notwithstanding 
the  great  number  of  accidental  productions  called  cancerous,  developed  in  dif- 
ferent parts  of  the  abdomen,  no  pain  was  ever  felt  ? The  enormous  tumour 
formed  by  the  liver  was  uniformly  free  from  pain,  and  yet  the  cancerous 
masses  which  had  in  a great  measure  taken  the  place  of  its  tissue  were  com- 
pletely softened ; blood  was  mixed  with  them,  and,  what  is  more,  they  were 
in  almost  immediate  contact  with  the  peritoneum  investing  the  circumference  of 
the  liver* 


DISEASES  OF  THE  ABDOMEN. 


.381 


Neither  do  we  find  in  this  case  any  trace  of  jaundice,  but  only  that  straw- 
colour  tint  of  the  face  which  accompanies  some  cancerous  affections,  and  which 
has  more  than  once  served  to  distinguish,  during  life,  simple  chronic  inflamma- 
tion of  a tissue  from  its  organic  degeneration. 

The  degeneration  of  the  pancreas,  of  which  we  had  here  an  instance,  is  a 
rare  fact  in  pathological  anatomy.  Most  frequently  it  is  found  intact  amidst 
the  most  serious  disorganisations  of  the  stomach  and  the  other  surrounding 
tissues.  Would  it  not  seem  that  in  this  case  it  was  principally  the  cellular 
tissue,  interposed  between  the  granulations  of  the  pancreas,  which  was  altered 
and  indurated ; and  that,  according  as  this  cellular  tissue  was  developed,  the 
granulations  were  atrophied,  and  ultimately  disappeared  ? Several  times  in  the 
salivary  glands,  and  once  in  the  lachrymal  gland,  have  we  been  able  to  trace 
the  process  of  disorganisation  now  alluded  to.  The  granulations  of  those  glands 
were  still  distinct,  but  merely  scattered,  and  separated  from  each  other  by  thick- 
ened and  indurated  cellular  tissue.  We  should  not  forget  to  remark  the  mis- 
chievous effects  produced  in  this  individual  by  the  application  of  blisters  to  the 
legs.  What  more  striking  instance  could  be  given  of  individual  predisposition  ! 
Thus,  in  certain  patients,  the  slightest  irritant  introduced  into  the  digestive  pas- 
sages will  occasion  the  most  alarming  symptoms  ; whilst  in  others  the  most 
violent  drastics  will  be  entirely  ineffectual. 

Case  26. — Cancer  of  the  liver  and  stomach — Ascites,  without  any  other  symptom  of  liver 

disease. 

A man,  sixty-five  years  of  age,  who  had  habitual  purging  for  the  last  year 
(three  or  four  liquid  stools  in  twenty-four  hours,  preceded  by  colicky  pains), 
felt  some  pains  in  the  epigastrium.  During  the  last  two  months  he  had  sour 
eructations  after  eating,  and  sometimes  had  a disposition  to  vomit.  Since  the 
last  month,  ascites,  and  some  oedema  of  the  lower  extremities  : no  pain  felt  in 
any  other  part  of  the  abdomen ; the  right  hypochondrium  was  never  painful. 
This  person  became  more  and  more  exhausted,  and  died. 

Post-mortem.  Considerable  effusion  of  limpid  serum  into  the  peritoneum  ; 
liver  of  the  ordinary  size,  concealed  behind  the  ribs,  seemingly  healthy  on  the 
outside,  but  presenting  internally  a great  number  of  cancerous  masses,  several 
of  which  were  softened.  These  masses  occupied  nearly  three  fourths  of  the 
organ,  the  healthy  tissue  of  which  was  nearly  reduced  to  a very  small  size. 
The  internal  surface  of  the  stomach  presented,  towards  the  middle  of  the  small 
curvature,  an  ulcer  broader  than  a five-franc  piece,  in  the  bottom  of  and  around 
which  the  sub-mucous  cellular  tissue  was  found  considerably  thickened,  scir- 
rhous, and  the  fleshy  tunic  hypertrophied.  In  the  large  intestine  the  mucous 
membrane  was  found  to  be  pale,  but  very  much  softened.  There  was  a little 
redness  at  the  termination  of  the  small  intestine.  The  apex  of  both  lungs  was 
hard  and  black ; in  the  midst  of  this  indurated  portion  small  grains  of  a stony 
consistence  were  found. 

In  this  case  there  was  neither  tumour  nor  pain  present  or  past,  nor  jaundice 
either  at  the  time,  or  previously,  to  characterise  the  disease  of  the  liver.  The 
ascites,  which  one  might  readily  see  did  not  depend  on  an  affection  of  the  heart, 
and  which  did  not  appear  to  be  attributable  to  an  inflammation  of  the  perito- 
neum, might  incline  one  to  think  that  there  was  disease  of  the  liver ; but,  if 
from  this  ascites  one  would  have  wished  to  announce  the  nature  of  the  disease 
with  which  the  liver  was  affected,  he  would  rather  have  diagnosed  the  existence 
of  one  of  those  hard,  small,  shrivelled  livers,  already  spoken  of,  than  that  of  a 
cancerous  liver  ; for  the  latter  produces  ascites  without  any  other  symptom, 
much  more  rarely  than  the  other  lesion.  Here  again,  as  in  most  of  our  other 
cases,  we  remark  the  simultaneous  existence  of  the  affection  of  the  liver  and  of 
the  digestive  tube  ; here  also  it  is  not  the  duodenum  which  we  see  to  be  spe- 
cially affected. 


3 82 


ANDRAL’S  MEDICAL  CLINIC. 


SECTION  III. 

OBSERVATIONS  ON  HYDATIDS  OF  THE  LIVER. 

Case  27.  — A chanter  in  a church,  thirty-one  years  of  age,  had  for  several 
years  indulged  in  alcoholic  liquors  to  excess.  Three  years  before  his  admission 
into  the  hospital  he  had  small-pox ; before  this  he  had  enjoyed  uniform  good 
health.  For  five  months  after  convalescence  from  this  he  had  purging,  accom- 
panied with  slight  abdominal  pains.  This,  however,  was  soon  removed  by 
proper  treatment.  Some  time  after,  he  began  to  feel  a dull  pain  towards  the 
right  hypochondrium  ; i-t  was  most  severe  during  the  night.  This  pain  was 
not  accompanied  by  any  very  bad  symptom  for  about  two  years.  At  the  end  of 
this  time  he  began  to  lose  flesh  and  strength.  For  six  months  he  wasted  away 
in  this  manner,  without  the  appearance  of  any  other  local  symptom  ; only,  from 
time  to  time,  he  had  returns  of  the  diarrhoea.  Appetite  good ; to  recruit  his  strength, 
he  still  indulged  in  wine  and  spirituous  liquors.  Six  months  before  coming  to 
the  hospital  he  perceived  that  he  was  yellow.  The  jaundice  which  was  at  first 
slight,  and  limited  to  the  face,  afterwards  became  general  and  very  marked. 
When  we  saw  him  first,  his  case  was  as  follows  : 

His  spirits  were  very  good,  and  he  was  very  confident  of  recovery  : still  he 
was  very  much  emaciated  ; the  greenish  hue  of  his  skin  indicated  a lesion  of 
the  liver.  On  a line  with  the  last  ribs  on  the  right  side,  and  in  the  hypochon- 
drium, there  was  a sort  of  weight,  an  unpleasant  sensation  rather  than  a real 
pain.  Wecould  not  discover  any  tumour  by  manual  examination;  everywhere 
else  the  abdomen  was  soft  and  free  from  pain.  Appetite  still  good.  For  seve- 
ral months  he  had  been  constipated  ; no  trace  of  dropsy ; pulse  not  frequent 
nor  skin  hot ; urine  red  and  scanty.  After  being  a month  in  the  hospital,  with- 
out presenting  any  change,  his  respiration  became  suddenly  embarrassed  with- 
out any  previous  stitch  in  the  side,  or  any  characteristic  sputa  ; auscultation 
first  detected  a crepitous  rale,  and  afterwards  well-marked  bronchial  respiration 
in  the  space  included  between  the  right  clavicle  and  the  mamma  of  the  same 
side,  and  posteriorly  in  the  supra  and  infraspinous  fossae.  Dull  sound  over  the 
same  space  ; at  the  same  time  features  became  very  much  changed  ; pulse 
thready  ; erysipelas  of  the  face  accompanied  with  increased  prostration.  He 
died  on  the  sixth  day  after  the  appearance  of  the  dyspnoea. 

Post-mortem.  Great  emaciation  ; abdominal  parietes  retracted  ; marked 
greenish-yellow  tinge  of  the  skin  ; no  trace  of  dropsy.  The  liver  viewed  exter- 
nally, was  healthy  ; it  was  of  its  natural  size  and  colour;  but  scarcely  had  the 
scalpel  entered  it  to  the  depth  of  eight  or  ten  lines,  when,  immediately  to  the 
right  of  the  great  suspensory  ligament,  a liquid  was  observed  to  gush  forth  with 
violence,  as  clear  as  crystal,  and  we  found  that  it  came  from  a pouch  large  enough 
to  hold  an  orange,  and  which  was  filled  with  seven  or  eight  acephalocysts,  one 
of  which  was  much  larger  than  the  others.  This  large  hydatid  was  hollow,  and 
it  was  from  it  that  the  clear  liquid  above  mentioned  seemed  to  come  ; that  sur- 
rounding the  hydatids,  and  contained  in  the  pouch  itself,  was  yellowish  and 
turbid.  The  parietes  of  this  pouch  were  formed  of  a fibrous  dense,  resisting  mem- 
brane, several  lines  in  thickness,  in  contact  at  its  external  surface  with  the  paren- 
chyma of  the  liver,  to  which  it  was  united  by  some  cellulo-vascular  filaments. 
Smooth  on  its  inner  surface,  where  it  presented  a serous  organisation,  it  was  bathed 
in  the  fluids  in  which  hydatids  float.  The  spleen,  healthy  on  the  outside,  when 
cut  into,  allowed  a fluid  to  escape  similar  to  that  which  came  from  the  liver. 
This  liquid  came  from  a large  acephalocyst,  which  contained  several  others,  and 
which  was  contained  in  a cavity  in  the  splenic  parenchyma ; this  cavity  differed 
from  that  found  in  the  liver  in  its  parietes  being  lined  only  with  a very  thin  cel- 
lular membrane.  In  the  lower  fifth  of  the  small  intestine  Peyer’s  glands  were 


DISEASES  OF  THE  ABDOMEN. 


383 


found  larger  than  usual,  uneven  on  the  surface,  some  of  a greyish  white,  and 
others  blackish.  In  this  same  portion  of  the  intestine  isolated  follicles  were  found 
very  apparent,  presenting  a central  black  point,  and  a circle  of  the  same  colour 
on  their  circumference.  The  inner  surface  of  the  caecum,  and  of  a portion  of 
the  colon,  presented  a slate-coloured  tint.  Grey  hepatisation  of  the  upper  lobe 
of  the  right  lung.  Some  whitish  flocculi  in  the  pleura"of  the  same  side,  with 
redness  of  this  membrane. 

One  fact  should  strike  us  in  the  case  now  read ; the  impossibility  of  detect- 
ing, by  any  distinctive  sign  during  life,  the  species  of  change  which  the  liver 
had  undergone.  What  do  we  find,  in  fact,  as  a symptom  of  the  disease  of  the 
liver  ? Nothing  else  but  what  the  preceding  cases  have  shown  to  us,  where, 
notwithstanding  the  organic  lesion  was  very  different,  these  symptoms  may 
be  reduced  to  an  obscure  pain,  with  jaundice.  Thus,  then,  whether  there  be 
simple  sanguineous  congestion  of  the  liver,  hypertrophy  or  atrophy,  induration 
or  softening  of  its  parenchyma,  formation  of  abscess,  or  development  of  cancer- 
ous tumours  in  its  interior,  production  of  hydatids,  etc.,  symptoms  sometimes 
different,  but  oftentimes  identical,  are  the  result  of  these  infinitely  varying 
lesions.  No  doubt  it  would  be  easier  and  more  convenient  to  the  observer  to 
be  able  to  assign  to  each  of  these  lesions  a particular  group  of  symptoms  ; to 
say,  for  instance,  that  lancinating  pains  uniformly  characterise  cancer  of  the 
liver,  that  hydatids  are  always  free  from  pain,  etc.  ; this  is,  to  be  sure,  most 
generally  the  case  ; but,  on  the  other  hand,  there  are  cancers  of  the  liver 
unattended  with  pain,  and  we  see  hydatids  accompanied  with  pains  sometimes 
very  acute  in  the  different  stages  of  their  existence.  The  knowledge  of  the 
exceptionable  cases  is  of  great  importance  to  the  practitioner  for  the  certainty 
of  his  diagnosis. 

Another  circumstance  of  this  case,  well  worthy  of  remark,  is  the  intestinal 
inflammation  which  here  preceded  the  development  of  hydatids  in  the  liver,  as 
it  very  frequently  precedes  the  development  of  an  ordinary  hepatitis,  whether 
acute  or  chronic.  On  this  point  we  may  refer  to  the  cases  already  cited  else- 
where^ and  in  which  we  have  seen  abscesses  of  the  liver,  hydatids  of  this  organ, 
atrophy,  and,  in  a word,  cancerous  degenerescences  of  its  parenchyma,  become 
developed  under  the  influence  of  one  and  the  same  order  of  causes,  namely, 
external  violence. 

Pain  was  for  a long  time  the  only  phenomenon  which  indicated  the  existence 
of  an  affection  of  the  liver  ; this  pain,  according  to  the  patient’s  account,  wa3 
more  severe  during  the  night ; a fact  which,  added  to  several  others,  may  serve 
to  prove  that  this  character  of  the  pain,  of  increasing  during  the  night,  is  not 
peculiar  to  syphilitic  pains.  We  often  observe  it,  for  instance,  in  the  cases  of 
simple  rheumatic  pains.  It  is  remarkable,  moreover,  that  the  same  hydatids, 
the  development  of  which,  in  the  liver,  had  been  accompanied  with  pain,  did 
not  occasion  any  in  the  spleen. 

It  would  be  very  difficult  to  account  for  the  production  of  the  jaundice  in  this 
case,  where  the  affection  of  the  liver  had  left  the  greater  part  of  the  parenchyma 
perfectly  healthy,  and  where  the  bile  ducts  were  also  exempt  from  any  kind  of 
lesion. 

The  individual  was  very  much  wasted,  and  was  advancing  slowly  towards 
the  grave,  but  nothing  as  yet  indicated  his  approaching  dissolution.  The  great 
functions,  those  whose  integrity  is  most  essential  to  the  support  of  life,  were  not 
yet  compromised.  Thus  the  circulation  was  not  disturbed,  notwithstanding  the 
twofold  pathological  process  of  which  the  liver  and  the  spleen  were  the  princi- 
pal seats  ; the  breathing  remained  free  ; the  gastric  digestion  (a  thing  remark- 
able in  a disease  of  such  long  continuance)  was  duly  performed ; there  was 
a desire  for  food ; chylification  seemed  to  be  performed ; but  the  matter 
formed  in  the  intestine,  and  absorbed,  was  to  no  purpose  carried  by  the  blood  to 


384 


ANDRAL’S  MEDICAL  CLINIC. 


the  different  organs  ; it  did  not  assimilate  with  their  tissue.  In  this  case  the 
normal  performance  of  the  general  movement  of  nutrition  was  impeded  by  the 
abnormal  movement  of  nutrition  which  took  place  in  the  liver  and  the  spleen. 

It  was  in  this  state  of  things  that  an  acute  inflammation  attacked  a portion  of 
the  pulmonary  parenchyma.  Here,  as  in  many  other  cases  where  pneumonia 
complicates  a chronic  disease,  the  symptoms  of  the  inflammation  are  far  from 
being  clearly  marked.  We  observe  no  characteristic  expectoration,  no  pain, 
though,  after  death,  undoubted  traces  of  inflammation  have  been  found  in  the 
pleura  : we  merely  observe  severe  dyspnoea ; and  further,  in  this  individual, 
who  was  already  exhausted,  the  pulmonary  inflammation  occasioned  a sudden 
sinking  of  the  strength,  an  adynamic  state,  which  the  erysipelas  of  the  face 
contributed  to  increase.  These  same  symptoms  are  frequently  occasioned 
under  similar  circumstances  by  a gastric  or  intestinal  inflammation. 

It  must  not  be  forgotten  that,  for  a long  time,  the  patient  was  subject  to  a 
diarrhoea,  which  was  succeeded  at  intervals  by  constipation.  The  unusual 
development  of  Peyer’s  glands,  hypertrophy  of  other  separated  follicles,  with 
the  appearance  of  a black  colour  at  their  centre  and  circumference,  the  slate- 
coloured  tint  of  apart  of  the  large  intestine,  are  so  many  lesions  which  indicated 
an  old  inflammatory  state  of  the  digestive  tube. 

CAse  28. — Hydatids  of  the  liver  developed  without  symptoms — Acute  peritonitis  consecutive 
on  the  opening  of  the  hydatid  pouch  into  the  peritoneum. 

A female,  twenty-seven  years  old,  entered  the  Charite  with  all  the  symptoms 
of  pulmonary  phthisis  in  an  advanced  stage  : a cavity  in  the  upper  lobe  of  the 
lung  ; diarrhcea,  sweats,  hectic  fever,  little  appetite ; abdomen  soft  and  free 
from  pain  in  every  part.  This  woman  was  declining  slowly,  when  she  was 
suddenly  seized,  without  any  known  cause,  with  an  acute  abdominal  pain, 
increased  by  the  least  pressure.  For  the  four  days  following  the  commence- 
ment of  this  pain,  the  abdomen  was  observed  to  swell,  always  continuing  very 
painful ; pulse  became  very  frequent  and  wreak.  She  died  whilst  vomiting 
some  greenish  bile. 

Post-mortem.  Turbid  flocculent  serum  in  the  peritoneum  ; intestinal  convolu- 
tions united  by  white  unorganised  pseudo  membranes  of  recent  formation.  On 
raising  the  liver  we  were  not  a little  surprised  to  find,  on  the  lower  surface,  a little  to 
the  right  of  the  gall  bladder,  a solution  of  continuity,  which  might  have  admitted 
the  end  of  three  fingers  joined  together,  and  which  led  into  a large  cavity  filled  with 
burst  hydatids.  We  then  thought  that  the  peritonitis  was  owing  to  the  opening 
of  the  hydatid  sac  into  the  cavity  of  the  serous  membrane.  Further  examina- 
tion detected  shreds  of  hydatid  membranes  floating  in  the  peritoneal  serum. 
Traces  of  inflammation  of  the  gastro-intestinal  mucous  membrane.  Tubercles 
in  different  stages  in  the  lungs. 

This  case  is  remarkable  in  two  points  of  view  : — First,  it  shows  that  hyda- 
tids may  form  in  the  liver,  be  developed  there,  and  attain  considerable  size, 
without  occasioning  any  symptoms  ; and  in  this  respect  it  will  not  be  uninter- 
esting to  compare  the  preceding  with  the  present  case.  In  the  preceding  case 
we  saw  that  these  same  hydatids  had  produced  pain  in  the  region  of  the  liver, 
and  also  jaundice.  With  respect  to  the  wasting  of  the  patient,  we  cannot  know, 
in  this  case,  what  share  the  affection  of  the  liver  had  in  its  production  in  con- 
sequence of  the  accompanying  disease  of  the  lungs.  Why,  in  one  of  these 
cases,  was  there  pain  and  jaundice  ? why,  in  the  other,  did  none  of  these  symp- 
toms exist  ? The  organic  changes  were  still  the  same.  Secondly,  this  case, 
moreover,  affords  an  instance  of  peritonitis  produced  by  the  opening  of  a cavity 
formed  in  the  liver  into  the  peritoneum,  and  by  the  serous  membrane  of  the 
foreign  bodies  passing  into  this  cavity. 


DISEASES  OF  THE  ABDOMEN. 


385 


Case  29. — Hydatids  of  the  liver,  with  considerable  development  of  this  organ,  and  suppuration 
in  the  hydatid  cavity — Tumour,  unattended  with  pain  or  fever,  for  a long  time ; at  a sub- 
sequent period,  pain  and  fever. 

A middle-aged  man  entered  the  Charite  in  the  following  state  : — a consider- 
able tumour  occupied  the  right  hypochondrium  as  well  as  the  epigastrium  ; it 
advanced  a little  towards  the  left  hypochondrium,  and  it  descended  as  low  as 
the  umbilicus  ; superiorly  it  appeared  to  be  continued,  and  lost  behind  the  ribs. 
This  tumour  was  smooth,  presented  no  knobs  ; pressure,  however  severe,  gave 
no  pain.  The  patient  told  us  that,  for  the  last  two  years  nearly,  he  had  per- 
ceived the  existence  of  this  tumour,  which  was  constantly  free  from  pain,  and 
had  increased  gradually,  without  the  digestive  functions  having  ever  been  seri- 
ously affected.  But  he  gradually  lost  flesh  and  strength;  pulse  not  frequent ; 
skin  dry,  not  hot ; no  jaundice  at  any  time  ; tongue  whitish  ; no  thirst ; appe- 
tite rather  good  ; stools  natural.  From  the  situation  of  the  tumour,  its  form, 
and  its  relations,  we  were  disposed  to  think  that  it  was  nothing  but  the  liver 
unusually  enlarged.  (Leeches  were  applied  several  times  over  the  right  hypo- 
chondrium, or  to  the  anus ; stimulating  frictions  to  the  skin  were  ordered ; 
purgative  pills  given.)  One  day  we  were  struck  with  the  great  alteration  in  the 
features  of  the  face,  which,  having  been  of  rather  a good  colour  till  then,  became 
remarkably  pale  ; pulse  now  frequent ; a dry  burning  heat  in  the  palms  of  the 
hands.  For  some  days  back  the  patient  felt,  in  the  right  hypochondrium, 
which  till  then  was  free  from  pain,  a somewhat  acute  pain,  which,  being  worse 
at  intervals,  was  then  become  lancinating.  From  the  absence  of  any  new  symp- 
toms, it  was  evident  that  the  cause  of  the  unfavourable  change  in  the  features  of 
the  face  and  of  the  fever  depended  on  a new  morbid  process  setup  in  the  liver. 
Leeches  were  again  applied  over  the  hypochondrium,  which  was  afterwards 
covered  with  emollient  and  narcotic  cataplasms.  The  pain  and  fever  were  still 
worse  on  the  next  day.  He  was  then  bled  from  the  arm  ; afterwards,  leeches 
were  again  applied  over  the  hypochondrium;  blisters  to  the  legs;  frictions  with 
tariar  emetic,  on  the  right  hypochondrium.  All  the  symptoms  became  worse  ; 
diarrhoea  set  in  ; and  he  died  in  a few  days. 

Post-mortem.  The  liver  occupied  all  the  space  included  between  the  edge 
of  the  false  ribs  of  the  right  side  superiorly,  and  a line  supposed  to  be  drawn 
from  the  superior  crest  of  the  ileum  towards  the  umbilicus.  Thus  it  was  it,  then, 
that  constituted  the  tumour  during  life.  In  one  point  of  its  convex  surface, 
towards  the  middle  of  its  right  lobe,  it  presented  a manifest  fluctuation.  AVhere 
this  did  exist,  there  was  found,  instead  of  the  parenchyma  of  the  liver,  a cavity 
which  might  have  held  two  oranges,  and  which  contained  two  distinct  matters-; 
first,  white  creamy  pus,  of  good  consistence  and  inodorous ; secondly,  in  the 
midst  of  this  pus  hydatids,  some  of  which  were  still  entire,  the  greater  part  of 
which  consisted  of  debris  of  membranes  rolled  on  each  other.  Those  which 
were  entire  presented  this  remarkable  circumstance,  that  several  points  of  their 
parietes  were  opaque,  and  of  a milky-white  colour.  After  this  cavit}r  had  been 
emptied,  its  parietes  were  found  to  be  lined  merely  with  a layer  of  concrete  pus, 
and  beneath  this  layer  was  the  parenchyma  of  the  liver  redder  and  more  friable, 
to  the  extent  of  some  lines  around  the  cavity,  than  anywhere  else.  Towards 
the  centre  of  the  left  lobe  a second  cavity  was  found  full  of  hydatids  still  entire. 
The  parietes  of  this  cavity  were  lined  with  a real  fibrous  membrane,  and  around 
it  no  appreciable  alteration  was  found  of  the  hepatic  parenchyma.  White  soft- 
ening of  the  gastric  mucous  membrane  towards  the  great  cul-de-sac  ; red  spots 
over  the  large  intestine. 

There  are  two  periods  to  be  distinguished  in  this  case.  In  the  first  we  per- 
ceive a considerable  tumour  in  the  right  hypochondrium  ; and  there  is  no  other 
serious  symptom,  except  the  progressive  emaciation  and  the  gradual  loss  of 
strength.  In  the  second  period  pain  and  fever  set  in,  all  the  functions  become 
33 


3S6 


ANDRAL’S  MEDICAL  CLINIC. 


gradually  deteriorated,  and  death  succeeds  to  a diarrhoea.  We  think  we  may 
easily  account  for  the  symptoms  of  these  two  periods  by  the  lesions  found  on 
the  dead  body.  It  seems  probable  that,  in  the  period  during  which  there  was 
neither  pain  nor  fever,  the  liver  contained  nothing  but  hydatids  ; at  a subsequent 
period  pus  came  to  be  secreted  around  these  entozoaires  ; thence  fever,  pain, 
and  that  series  of  symptoms  which  generally  accompany  every  suppuration. 
This  is  not  the  only  case  wherein  we  have  observed  divers  new  products 
become  developed  around  hydatids,  pus  as  well  as  tuberculous  matter.  We  shall 
annex  to  this  the  history  of  another  case  recently  communicated  by  Dr.  Descieux. 
In  this,  as  well  as  in  that  how  cited,  one  and  the  same  cavity  contained  pus 
and  hydatids  at  one  and  the  same  time. 

An  inhabitant  of  Montfort-Lamaury  laboured  for  more  than  twenty  year3 
under  what  are  called  obstructions  ; seven  years  ago  he  passed  hydatids  by  the 
anus  ; he  was  very  unhappy  in  his  state.  Three-fourths  of  the  upper  part  of 
the  abdomen  were  occupied  by  a knobby  tumour,  the  seat  of  which  could  not 
readily  be  determined.  About  two  months  before  this  case  was  written  the  patient 
felt  acute  pains  in  the  abdomen,  and  fever  set  in  ; seven  weeks  after  these  symp- 
toms appeared,  one  of  the  most  prominent  knobs  of  the  tumour  became  fluctua- 
ting ; he  experienced  very  acute  pains  in  the  part.  An  incision  was  made  on 
the  summit  of  the  tumour  ; this  incision  was  made  four  fingers’  breadth  from 
the  linea  alba  of  the  left  side.  A large  quantity  of  pus  gushed  from  it,  and  a 
brown  liquid,  similar  to  that  which  is  sometimes  met  in  ovarian  cysts;  mem- 
branes also,  several  inches  in  length,  escaped  from  it,  of  a yellowish  colour,  and 
altogether  resembling  the  debris  of  hydatids;  they  were  soft  and  friable,  and 
had  lost  their  consistence.  M.  Descieux  considered  them  to  be  dead  hydatids. 
During  the  four  following  days,  pus  and  some  debris  of  hydatids  flowed  in  abun- 
dance between  the  lips  of  the  incision.  At  the  time  this  case  was  written  the 
discharge  consisted  merely  of  pus  without  any  admixture  of  hydatids.  The 
abdomen  was  soft  and  very  little  painful ; all  the  knobs  disappeared  ; the  patient 
was  still  very  weak,  but  not  feverish  ; the  evacuations  were  free. 


SECTION- IV. 

DISEASES  OF  THE  EXCRETORY  PASSAGES  OF  THE  BILE. 

The  different  tissues  which  enter  into  the  composition  of  the  parietes  of  the 
gall-bladder,  as  well  as  the  ductus  choledochus,  cysticus  and  hepaticus,  may  be 
attacked,  separately  or  simultaneously,  with  acute  or  chronic  inflammation.  This 
inflammation  may  be  limited  to  a more  or  less  circumscribed  point  of  the  gall- 
bladder or  ducts ; it  may  also  attack  them  through  their  entire  extent.  Some- 
times, whether  by  mere  anatomical  inspection,  or  by  the  study  of  the  symptoms, 
one  is  led  to  admit  that  inflammation  of  the  passages  for  the  excretion  of  bile  is 
consecutive  on  an  inflammation  of  the  duodenum  ; sometimes,  on  the  contrary, 
there  is  nothing  to  prove  this  dependence ; there  is  nothing  to  prove  that  the 
inflammatory  process  which  has  attacked  these  passages  of  excretion  is  not 
primary.  Is  it  not  thus  with  external  parts  ? And -if,  for  instance,  observation 
teaches  us  that  in  a very  great  number  of  cases  inflammation  of  the  passages  for 
the  excretion  of  serum  or  saliva  is  consecutive  on  a urethritis  or  a stomatitis,  are 
there  not  other  cases  also  where  either  acute  or  chronic  engorgement  of  the 
testicle,  or  an  inflammation  of  Stheno’s  duct,  or  of  the  ducts  which  by  their 
union  form  it,  are  seen  to  supervene,  without  there  having  been  any  previous 
inflammation  of  the  urethra  or  of  the  cavity  of  the  mouth  ? 

The  changes  of  texture  induced  by  inflammation  in  the  passages  for  the  excre- 


DISEASES  OF  THE  ABDOMEN. 


387 

tion  of  bile  are  numerous,  and  of  several  kinds.  First,  they  may  be  limited  to 
the  mucous  membrane,  or  extended  to  the  subjacent  tissues. 

The  mucous  membrane  may  be  ulcerated,  as  M.  Louis  has  proved  by  several 
cases  ; we  have  found  it  considerably  tumefied,  thickened,  and  hypertrophied, 
after  different  acute  or  chronic  inflammations.  If  this  increase  in  thickness 
exists  only  in  the  portion  of  membrane  which  lines  the  inner  surface  of  the 
gall-bladder,  no  particular  phenomenon  results  from  it;  but  the  same  cannot 
be  said  with  respect  to  the  ducts,  whose  mucous  membrane  cannot  be  tumefied 
without  complete  or  partial,  permanent  or  temporary,  obliteration  of  these 
ducts. 

The  tissues  subjacent  to  the  mucous  membrane  may  also  undergo  different 
species  of  change.  In  the  gall-bladder  we  have  several  times  found  them  infil- 
trated with  serum,  and  once  with  purulent  matter.  In  this  same  gall-bladder  we 
have  seen  them  sometimes  softened,  extensively  ulcerated  and  perforated  simul- 
taneously with  the  mucous  membrane,  which  occasioned  an  effusion  of  bile  into 
the  peritoneum  ; sometimes  very  much  thickened,  indurated,  and  scirrhous ; at 
other  times  changed  into  fibrous  or  cartilaginous  tissues,  or  studded  with  bony 
depositions  ; on  another  occasion  reddish  fibres  of  a muscular  appearance  were 
observed  on  the  parietes  of  the  gall-bladder.  In  the  ductus  hepaticus,  cysticus 
and  choledochus,  the  submucous  cellular  tissue  may  also  be  either  softened  and 
destroyed  simultaneously  with  the  mucous  membrane,  occasioning  perforation  of 
some  point  of  the  parietes,  or  be  thickened  and  indurated,  and  thus  produce 
obliteration  of  these  ducts  in  the  same  way  as,  in  the  canal  of  the  urethra,  certain 
indurations  of  the  submucous  cellular  tissue  frequently  cause  it  to  be  very  much 
diminished. 

In  some  cases  all  trace  is  lost  of  the  cavity  either  of  the  ductus  hepaticus, 
cysticus  or  choledochus.  In  their  stead  nothing  is  found  but  a mere  fibrous 
chord.  The  cavity  of  the  gall-bladder  may  also  be  very  much  diminished,  be 
even  completely  effaced,  and,  where  it  did  exist,  it  sometimes  happens  that 
nothing  is  found  but  a small  body,  in  which  the  cystic  duct  itself,  also  ob- 
literated, terminates;  it  may  disappear  still  more  completely,  and  the  depres- 
sion in  which  it  was  lodged  may  be  occupied  by  cellular  tissue  more  or  less 
condensed. 

At  other  times,  on  the  contrary,  the  cavity  of  the  gall-bladder  is  found  much 
larger  than  usual ; this  appears  to  happen  chiefly  incases  where,  there  being  an 
obstacle  to  the  free  passage  of  the  bile  into  the  ductus  choledochus,  this  liquid 
flows  back,  and  accumulates  in  the  gall-bladder,  from  which  it  can  no  longer  make 
its  exit,  so  as  to  flow  into  the  duodenum. 

This  same  increase  of  size  may  also  exist  in  portions  even  of  the  biliary  ducts 
which  are  situate  behind  an  obstacle.  In  one  case,  where  a calculus  closed  up 
the  duodenal  orifice  of  the  ductus  choledochus,  we  found  this  duct  so  dilated 
through  the  remainder  of  its  extent  that  its  diameter  equalled  that  of  the  vena 
portae. 

Every  one  knows  that  the  materials  of  the  bile  may  become  solidified  in  the 
excretory  passages,  so  as  to  form  calculi,  which  vary  very  much  in  their  che- 
mical composition,  in  their  form,  colour,  dimensions,  number,  seat,  etc.  We 
shall  not  here  enter  into  the  history  of  biliary  calculi.  We  shall  merely  call 
the  attention  of  chemists  to  a white  calculus,  composed  merely  of  phosphate  of 
lime  found  by  us  in  a gall-bladder,  which  contained  nothing  around  it  but  a 
little  mucus.  In  another  case  we  found  the  gall-bladder  filled  with  pus  instead 
of  bile. 

The  symptoms  occasioned  by  the  different  alterations  in  the  excretory  passages 
of  the  bile  now  considered  vary  according  to  the  nature  and  seat  of  these  altera- 
tions. 

The  gall-bladder  may  be  filled  with  calculi,  and  even  with  pus  ; its  parietes 
may  be  the  seat  of  different  alterations ; its  cavity  may  have  diminished  con- 


388 


ANDliAL’S  MEDICAL  CLINIC. 


siderably,  or  even  have  disappeared  ; it  may  cease  to  receive  any  bile  in  conse- 
quence of  the  obliteration  of  the  cystic  duct,  without  any  of  these  lesions  producing 
during  life  any  morbid  phenomenon  which  could  indicate  them. 

The  gall-bladder  distended  very  much  by  bile  or  by  other  matter  (calculi,  pus, 
etc.)  may  pass  beyond  the  edge  of  the  liver,  and  form  a tumour  in  different  points 
of  the  abdomen,  where  it  becomes  sensible  to  manual  examination.  We  have 
detected  it,  1st,  immediately  beneath  the  cartilaginous  edge  of  the  ribs  of  the 
right  side  ; 2dly,  lower  down  in  the  hypochondrium,  either  directly  perpendicu- 
larly downwards,  and  corresponding  to  the  place  it  usually  occupies,  or  inclined 
considerably  backwards  or  forwards  ; projecting,  for  instance,  into  the  epigas- 
trium ; 3dly,  we  have  seen  it  touch  the  crest  of  the  ileum,  and  even  descend 
before  it  as  far  as  the  iliac  fossa. 

This  tumour  thus  formed  by  the  gall-bladder  may  not  disappear,  once  it  has 
shown  itself.  At  other  times  it  is  observed  to  disappear  after  a longer  or 
shorter  time.  This  disappearance  comes  on  principally  under  the  following  cir- 
cumstances : 1st,  when  th^  obstacle  which  prevented  the  passage  of  the  bile 
into  the  ductus  choledochus  ceases  to  exist;  2dly,  when  the  bile,  at  first  accu- 
mulated in  its  reservoir,  becomes  afterwards  absorbed,  and  the  gall-bladder, 
no  longer  receiving  any  additional  bile,  has  a tendency  to  become  atrophied  ; 
3dly,  when  the  parietes  of  this  same  gall-bladder,  distended,  and  more  or  less 
changed,  come  to  be  perforated;  whence  there  is  a flow  of  bile  either  into  the 
peritoneum,  or  into  some  other  hollow  organ,  with  whose  cavity  the  gall-bladder 
accidentally  communicates,  or  externally,  in  the  case  where  adhesions  are  pre- 
viously established  between  the  gall-bladder  and  the  abdominal  parietes  ; and  the 
latter  have  in  their  turn  become  inflamed,  ulcerated  from  within  outwards,  and 
perforated. 

In  speaking  of  the  different  changes  which  may  effect  the  hepatic  parenchyma, 
we  stated  that  jaundice  might  come  on  in  all,  but  was  not  necessarily  the  result 
of  any.  Observation  proves,  on  the  contrary,  that  every  time  there  is  oblitera- 
tion either  of  the  ductus  hepaticus,  or  ductus  choledochus,  jaundice  is  produced. 
This  obliteration  may  be  occasioned  either  by  a foreign  body  which  obstructs 
the  cavity  of  the  ducts,  or  by  tumours  which  compress  it  from  without  inwards, 
or  by  a process  of  inflammation  which  has  produced  engorgement  and  thicken- 
ing of  the  mucous  membrane,  or  that  of  the  subjacent  tissues.  It  may  be  readily 
seen  that  jaundice,  owing  to  obliteration  by  one  of  these  causes,  must  be,  as 
the  obliteration  itself,  temporary  or  permanent. 

Some  persons  have  admitted  a jaundice  from  spasm  of  the  bile  ducts  ; but  this 
spasm  has  rather  been  asserted  than  proved  ; and  whilst  we  admitted  that,  under 
the  influence  of  certain  modifications  of  the  nervous  system,  the  liver  may  be 
changed  in  its  mode  of  secretion,  so  as  to  occasion  jaundice,  we  think  that  the 
cause  of  the  production  of  this  jaundice  resides  within  the  parenchyma  of  the 
organ,  where  the  act  of  secretion  is  going  on,  and  not  in  the  excretory  pas- 
sages of  the  bile,  the  spasmodic  contraction  of  which  appears  to  be  a mere 
hypothesis. 

It  follows,  as  a corollary,  from  our  observations,  that  in  a very  great  number 
of  cases  jaundice  is  produced,  and  continues  a longer  or  shorter  time  without 
there  being  any  appreciable  obstacle  in  the  excretory  passages  of  the  bile.  The 
truth  of  this  has  also  been  admitted  by  M.  Louis. 

The  following  cases  will  point  out  the  most  important  lesions  which  the  ex- 
cretory passages  of  the  bile  may  undergo,  and  the  different  symptoms  to  which 
these  lesions  may  give  rise. 

Case  30. — Acute  inflammation  of  the  ductus  choledochus  ; obliteration  of  its  cavity — Rupture 

of  the  ductus  hepaticus  by  distension  of  its  parietes— Jaundice,  with  pain  in  the  right  hypo- 
chondrium, and  a tumour  in  this  same  region  formed  by  the  gall-bladder — Peritonitis. 

A shoemaker,  thirty-five  years  of  age,  entered  the  Charite  November  8th. 


DISEASES  OF  THE  ABDOMEN. 


389 


Six  days  before,  after  an  excess  at  table,  he  was  seized  with  an  acute  pain  to 
the  right  of  the  epigastrium,  a little  below  the  edge  of  the  ribs.  On  the  day 
after,  he  perceived  that  his  skin  was  of  a yellow  colour.  November  9th  he 
presented  the  following  state ; yellow  tint  of  the  conjunctivae  and  of  the  entire 
cutaneous  surface  ; dull  pain  in  the  right  hypochondrium ; beneath  the  anterior 
extremity  of  the  eleventh  rib  a pyriform  tumour  is  felt,  moveable  under  the 
finger,  not  painful ; the  large  extremity  of  which  passes  a little  below  the  line 
of  the  umbilicus,  the  small  extremity  being  lost  behind  the  ribs.  Tongue 
natural,  thirst  not  great ; appetite  none,  stools  scanty,  and  devoid  of  colour. 
Pulse  frequent,  skin  hot  and  dry.  We  considered  the  tumour  of  the  hypo- 
chondrium  produced  by  the  gall-bladder  filled  with  bile  (leeches  to  the  anus  ; 
whey  with  acetate  of  potass  ; strict  diet).  The  four  following  days  the  tumour 
increased  ; no  other  change  took  place.  On  the  13th,  he  was  seized  on  a sud- 
den with  a much  more  acute  pain,  which,  setting  out  from  the  hepatic  region, 
soon  involved  the  entire  abdomen.  When  we  saw  the  patient  on  the  next 
morning,  this  pain  still  continued  ; its  extreme  acuteness,  and  its  being  increased 
by  the  least  pressure,  sufficiently  proved  that  it  was  occasioned  by  peritoneal 
inflammation ; at  the  same  time  the  face  was  pale,  features  sharpened,  and  very 
much  changed,  great  anxiety;  pulse  small  and  very  frequent  ; extremities  now 
cold,  (two  blisters  to  the  legs,  twenty  leeches  over  the  abdomen).  He  died  in 
the  afternoon. 

Post-mortem. — The  peritoneum  was  filled  with  a purulent  liquid,  the  colour  of 
which  was  in  general  yellow,  but  much  more  so  in  the  right  flank.  The  inner 
surface  of  the  duodenum  presented  an  entirely  red  colour.  The  point  where  the 
ductus  choledochus  opened,  and  which,  under  ordinary  circumstances,  is  found 
very  readily,  was  marked  by  a small*  rounded  tumour,  pierced  at  its  centre  by  a sort 
of  capillary  orifice,  the  breadth  of  a line  at  most,  and  raised  about  three  lines 
above  the  level  of  the  intestinal  surface.  A very  fine  probe  introduced  into  the 
orifice,  on  the  centre  of  this  tumour,  at  first  met  no  cavity.  However,  when 
pushed  in  with  force,  it  appeared  to  get  clear  of  some  obstacle,  and  was  soon  in 
the  dubtus  choledochus,  the  extent  of  which  it  traversed  with  some  difficulty,  as  if 
the  ordinary  cavity  of  the  canal  was  effaced,  and  as  if  the  probe  restored  it  a little 
according  as  it  was  pushed  carefully  from  the  intestine  towards  the  liver.  When 
cut  into  in  different  directions,  the  ductus  choledochus  presented  an  almost 
imperceptible  cavity  ; its  parietes  were  considerably  thickened,  they  were  very 
friable,  and  very  easily  torn.  On  the  contrary,  the  ductus  hepaticus  and  cysticus 
were  considerably  increased  in  size,  as  also  the  gall-bladder.  A little  before 
the  union  of  these  two  ducts,  the  hepatic  duct  presented  a solution  of  continuity 
of  an  irregularly-rounded  form,  and  large  enough  to  admit  a small  pea.  The 
texture  of  the  parietes  of  the  canal  around  this  perforation  did  not  appear  changed. 
The  cause  of  the  peritonitis  was  now  very  evident.  Some  red  patches  on  the 
mucous  membrane  of  the  stomach. 

There  are  few  cases  wherein  the  symptoms  observed  during  life  correspond 
so  accurately  with  the  lesions  found  on  the  dead  body.  In  consequence  of  an 
irregularity  in  diet,  the  stomach  and  duodenum  became  inflamed  ; the  inflamma- 
tion,  which  was  but  slightly  marked  in  the  first  of  these  organs,  became  much 
more  severe  in  the  second  ; the  irritation  of  the  duodenal  mucous  membrane 
extended,  by  continuity  of  tissue,  to  the  portion  of  membrane  lining  the  ductus 
choledochus.  Thus  the  lachrymal  ducts  are  inflamed  in  ophthalmia,  and  the 
seminal  ducts  in  urethritis ; thence  engorgement  of  the  mucous  membrane,  ob- 
literation of  the  cavity  of  the  ductus  choledochus,  and  consequent  accumulation 
of  bile  in  the  gall-bladder,  formation  of  the  tumour  in  the  hypochondrium,  pro- 
bable reabsorption  of  another  portion  of  the  bile,  and  production  of  jaundice. 
With  respect  to  the  hepatic  duct,  its  increased  capacity  seems  to  prove  that  it 
had  been  very  much  distended  with  bile.  Was  this  distension  pushed  far 
33* 


390 


ANDRAL’S  MEDICAL  CLINIC. 


enough  to  occasion  rupture  of  the  parietes  ? One  may  suppose  it,  in  conse- 
quence of  their  attenuation.  Another  remarkable  circumstance  is,  that  the 
inflammation,  which  was  very  severe  throughout  the  entire  ductus  choledochus, 
was  confined  to  this  duct,  and  that  the  hepatic  and  cystic  ducts  were  entirely 
exempt  from  it.  Other  mucous  surfaces  also  present  frequent  instances  of  in- 
flammation, the  seat  of  which  is  found  to  be  accurately  circumscribed,  as  here. 
Thus,  in  the  great  majority  of  cases  of  gastritis,  the  redness  of  the  mucous 
membrane  terminates  abruptly,  on  the  one  hand,  at  the  cardia,  and,  on  the  other 
hand,  at  the  pylorus.  Thus,  it  is  not  uncommon  to  see  one  of  the  surfaces  of 
the  ileo-caecal  valve  present  a bright  red  colour,  whilst  the  other  surface  is 
white.  This  change  of  colour  occurs  abruptly.  No  shade,  no  intermediate 
tint,  separates  the  inflamed  from  the  healthy  spot. 

Case  31. — Chronic  inflammation  of  the  ductus  choledochus  and  cysticus : obliteration  of  their 
cavity  by  thickening  of  the  parietes ; softening  and  rupture  of  the  parietes  of  the  gall-bladder. 
— Jaundice — Super-acute  peritonitis. 

A man,  sixty-four  years  of  age,  entered  the  Charite  in  December,  1821. 
Three  months  before,  he  had  been  seized,  without  any  known  cause,  with  bilious 
vomiting,  which  lasted  several  days.  This  ceased  spontaneously,  but  was  suc- 
ceeded by  profuse  diarrhoea,  which  continued  about  a month,  and  exhausted  the 
patient.  Towards  the  middle  of  September  the  diarrhoea  diminished,  but  the 
patient’s  strength  did  not  return.  Appetite  was  nearly  gone,  and  digestion  of 
food  became  difficult.  Yellow  tint  of  eyes,  and  of  the  entire  skin,  then  began 
to  be  perceptible.  At  the  time  of  his  entering  the  hospital  he  presented  the 
following  state  : — The  entire  skin  was  of  a yellow  colour,  bordering  a little  on 
green  ; emaciation  considerable  ; tongue  nearly  natural,  but  there  was  complete 
anorexia.  The  little  food  which  he  took  occasioned  in  the  epigastric  region  a 
sensation  of  weight  and  heat,  which  lasted  for  several  hours.  Stools  scanty,  of 
an  ashy-grey  colour.  The  abdomen,  when  carefully  examined,  presented  no 
tumour;  it  was  everywhere  soft  and  free  from  pain.  The  pulse  became  a little 
accelerated  only  towards  evening.  A blister  applied  over  the  epigastrium  was 
of  some  effect  in  assisting  digestion.  Leeches  had  been  applied  without  any 
advantage.  Milk  and  soups  were  his  principal  diet.  About  fifteen  days  after 
his  admission  the  state  of  the  stomach  seemed  to  be  improved  ; the  evening 
fever  was  much  less  marked,  but  the  jaundice  continued  ; the  strength  did  not 
return  ; emaciation  increased.  One  morning,  when  attempting  to  sit  down,  he 
felt  at  once  a sort  of  tearing  in  the  right  hypochondrium.  Some  minutes  after 
an  acute  pain  was  felt  at  first  in  the  right  side,  then  all  over  the  abdomen.  On 
the  next  morning  he  presented  all  the  symptoms  of  acute  peritonitis.  From 
the  sudden  way  in  which  it  had  commenced,  and  the  well-marked  sensation 
of  tearing  experienced  by  the  patient,  we  were  disposed  to  refer  it  to  intestinal 
perforation  as  its  cause.  He  died  during  the  night. 

Post-mortem.  — A great  quantity  of  a dirty  grey  liquid  was  effused  into  the 
peritoneum,  which  had  been  already  covered  with  membraniform  concretions 
in  several  points.  The  gall-bladder,  which  was  very  much  reduced  in  size, 
presented  in  its  lower  surface,  not  far  from  its  large  extremity,  a solution  of 
continuity  about  the  breadth  of  a five-sous  piece.  The  parietes  of  the  gall-blad- 
der were  remarkable  for  their  great  friability.  On  endeavouring  to  penetrate 
from  the  interior  of  the  gall-bladder  into  the  cystic  duct,  we  could  not  enter  it. 
Then  making  an  incision  in  the  ductus  choledochus,  to  ascend  from  this  duct 
into  the  cystic,  we  discovered  that  the  cavity  of  these  two  ducts  was  become  so 
small,  that  it  was  impossible  to  introduce  the  finest  probe  into  it.  This  almost 
total  obliteration  was  produced  by  thickening  of  their  parietes.  The  ductus 
hepaticus,  on  the  contrary,  was  very  much  dilated,  and  filled  with  biliary  con- 
cretions. The  mucous  membrane  of  the  stomach  was  of  a slate  colour,  and 


DISEASES  OF  TIIE  ABDOMEN. 


391 


was  very  much  thickened,  as  were  also  the  subjacent  cellular  and  muscular 
tunics  ; the  dura  mater  was  very  yellow. 

Here  again  an  almost  total  obliteration  of  a portion  of  the  bile  ducts  was  occa- 
sioned, very  probably,  by  an  inflammatory  state  of  these  ducts.  The  disease 
first  appeared  under  the  form  of  a simple  gastro-intestinal  inflammation ; this 
inflammation  soon  extended  to  the  bile  ducts  ; and  their  engorgement  produced 
the  jaundice  : this  case,  however,  differs  from  others  which  we  have  seen  in 
this,  that  here  the  inflammation  passed  into  the  chronic  state,  and  after  lasting 
several  months  produced  such  thickening  of  the  bile  ducts,  that  if  the  patient 
had  lived  some  months  longer,  it  is  probable  that  their  obliteration  would  have 
been  complete,  and  they  would  have  been  found  changed  into  a sort  of  ligamen- 
tous cord.  The  obliteration  of  the  cystic  canal  explains  why,  in  this  case,  the 
gall-bladder,  far  from  being  distended  and  forming  a tumour,  was,  on  the  con- 
trary, found  to  be  very  much  reduced  in  size.  The  parietes,  which  were  soft- 
ened and  friable,  seemed  to  have  participated  in  the  inflammation  of  the  ductus 
cysticus  and  choledochus  ; only  the  inflammatory  process  w'hich  had  thickened 
and  hardened  the  parietes  of  these  ducts,  had,  on  the  contrary,  softened  the 
parietes  of  the  gall-bladder.  We  should  not  be  astonished  at  these  two  opposite 
effects  of  inflammation  in  different  parts  of  the  same  tissue  ; mucous  membranes 
present  frequent  instances  of  the  same  thing.  Thus  the  same  symptoms  of 
inflammation  having  existed,  we  sometimes  find  the  gastric  mucous  membrane 
so  softened,  that  it  forms  merely  a sort  of  organised  pulp  ; sometimes,  on  the 
contrary,  it  is  found  thicker  and  harder  than  natural  ; the  same  thing  holds 
good  in  those  individuals  in  whom  these  two  morbid  states  are  found  combined 
in  different  parts  of  the  stomach.  The  rupture  of  the  softened  parietes  of  the 
gall-bladder  comes  under  the  head  of  those  cases  of  perforation  of  the  stomach, 
where  rupture  of  the  parietes  of  this  viscus  is  but  the  last  degree  of  their 
softening. 

Case  32. — Transformation  of  the  cystic  duct  into  a fibrous  cord — Considerable  dilatation  of  the 
ductus  choledochus  without  the  existence  of  any  obstacle  at  its  duodenal  extremity  : phos- 
phate of  lime  calculi  in  the  gall-bladder — Liver  large  and  granulated — Ascites,  no  jaundice 
— Latent  pericarditis. 

A merchant,  fifty  years  of  age,  had  been  unfortunate  in  some  speculations, 
and  had,  in  consequence,  suffered  great  mental  disquietude  — this  was  in  1815; 
his  health,  till  then  good,  began  to  decline ; he  had  jaundice,  which  was  but 
temporary,  then  ascites. 

In  1816  he  had  the  operation  of  paracentesis  performed  twice  ; during  the  nine 
years  following  his  health  was  uniformly  bad.  In  1817  the  ascites  disappeared 
spontaneously,  and  did  not  return  till  some  months  before  his  admission  into 
the  hospital  (1825). 

When  we  saw  him  there  was  a large  tumour  in  the  right  hypochondrium  ; 
it  was  felt  as  far  as  the  vicinity  of  the  umbilicus ; it  had  never  been  painful. 
The  abdomen  was  very  much  swollen,  and  evidently  the  seat  of  fluctuation. 
The  extremities  were  not  infiltrated  ; they  were  only  once  so  in  1816.  Tongue 
natural,  appetite  good,  pulse  very  small,  a little  frequent;  cough  and  short 
breathing  since  the  last  year.  This  patient  had  been  but  a few  days  in  the 
hospital ; he  still  retained  some  strength  ; he  used  to  rise  from  bed,  and  walk 
2^bout  the  ward,  when  one  morning  he  was  found  in  a state  of  coma  ; extremi- 
ties cold,  pulse  imperceptible.  He  died  two  hours  after  the  visit. 

Post-mortem.  Abdomen  very  much  depressed,  which  in  the  preceding  visit 
we  found  considerably  swollen.  Face  and  limbs  emaciated. 

Cranium . Cellular  adhesions  of  the  arachnoid  lining  the  dura  mater  to  that 
lining  the  superior  and  lateral  parts  of  the  cerebral  hemispheres  ; subarachnoid 
cellular  tissue  infiltrated  with  a considerable  quantity  of  serum  ; the  lateral  ven- 


392 


ANDRAL’S  MEDICAL  CLINIC. 


tricles  also  contained  a considerable  quantity  ; they  remained  dilated  even  after 
the  fluid  was  allowed  to  escape. 

Thorax.  The  old  cellular  adhesions  of  the  pleurae  costalis  and  pulmonalis  ; 
numerous  miliary  tubercles  on  the  centre  of  the  upper  lobes  of  each  lung. 
Pericardium  distended  with  three  glasses  of  a red  liquid,  like  blood  as  it  comes 
from  a vein.  All  the  internal  surface  of  the  pericardium  was  lined  with  false 
membranes  lying  one  on  the  other. 

Abdomen.  The  peritoneum  contained  but  a small  quantity  of  serum.  The 
liver  was  closely  united  by  false  membranes  on  the  one  hand  to  the  diaphragm, 
and  on  the  other  hand  to  the  spleen,  stomach,  and  colon.  Thick  false  mem- 
branes kept  the  gall-bladder  from  view,  which,  being  reduced  to  a very  small 
size,  contained  merely  some  thready  mucus,  and  three  small  concretions  of  a 
dull  white  colour,  which  were  found  to  consist  of  phosphate  of  lime.  The 
cystic  duct  was  changed  into  a fibrous  cord  as  far  as  its  entrance  into  the  hepatic 
duct ; at  the  point,  where  these  two  ducts  separated,  a small  calculus  was  found, 
similar  to  the  ordinary  biliary  calculi.  The  ductus  choledochus  was  three  times 
its  ordinary  size.  A hard  tissue,  several  lines  in  thickness,  and  of  a scirrhous 
appearance,  lay  between  the  peritoneum  which  covers  the  two  surfaces  of  the 
liver  and  the  proper  membrane  of  this  viscus,  which,  beneath  this  accidental 
tissue,  appeared  in  the  form  of  a slightly  undulating  line.  The  liver  was  very 
large,  and  passed  several  fingers’  breadth  beyond  the  edge  of  the  ribs ; it 
extended  into  the  left  hypochondrium.  Whence  cut  into  indifferent  directions, 
it  everywhere  presented  a remarkably  dense  tissue  of  a greyish-white  colour, 
and  streaked  with  a great  number  of  granulations.  Spleen  very  large  ; red  spots 
in  the  duodenum. 

Though  this  case  is  incomplete  in  several  points,  it  possesses  some  interest 
in  more  than  one  respect.  First,  it  will  be  observed  that  there  was  no  jaundice 
here ; and  accordingly,  the  cystic  duct  alone  was  obliterated.  The  bile  no 
longer  reached  the  gall-bladder,  which  contained  merely  some  mucus,  and  concre- 
tions entirely  foreign  in  their  nature  from  biliary  calculi.  What  was  the  cause 
of  the  great  dilatation  of  the  ductus  choledochus?  Was  its  cavity  enlarged,  in 
order  to  supply  the  gall-bladder,  and  to  discharge,  by  its  increase  of  size,  the 
functions  of  a reservoir?  In  support  of  this  idea  it  may  be  remarked,  that,  in 
several  animals  who  have  no  gall-bladder,  and  in  men  who  have  been  deprived 
of  it,  a similar  dilatation  of  the  ductus  choledochus  has  been  observed. 

We  have  more  frequently  found  such  an  enlargement  of  the  cavity  of  the 
biliary  ducts  behind  a calculus  which  obstructed  some  point  of  their  extent. 
Among  other  cases  of  this  kind,  we  may  mention  that  of  an  individual,  more 
than  sixty  years  of  age,  whose  gall-bladder  and  biliary  ducts  contained  a great 
number  of  calculi.  Several  were  accumulated  towards  the  duodenal  extremity 
of  the  ductus  choledochus,  and  completely  stopped  up  its  orifice.  This,  when 
seen  in  the  duodenum,  was  more  apparent  than  usual,  and  presented  at  its  cir- 
cumference a sort  of  puffiness,  which  made  it  resemble  the  anus.  Behind  this 
collection  of  calculi,  the  ductus  choledochus  had  undergone  such  dilatation,  that 
its  diameter  equalled  that  of  the  vena  portae.  The  same  maybe  said  of  the 
ductus  cysticus  and  hepaticus.  The  branches  which  formed  the  latter,  being 
filled  with  calculi,  were  also  so  dilated,  that  one  of  them  when  open  might 
admit  the  index  and  middle  finger  united. 

This  case,  again,  presents  another  instance  of  the  coincidence  of  a state  of 
coma  terminating  in  death,  with  the  sudden  disappearance  of  the  liquid  of  a 
dropsy,  without  any  supplementary  evacuation  being  set  up. 

The  false  membranes,  which  surrounded  the  liver,  and  which  united  it  to 
several  neighbouring  parts,  were  not  indicated  in  their  formation  by  any  acute 
pain.  The  lesion  of  the  pericardium  was  not  less  obscure.  The  pulmonary 
tubercles  were  not  announced  by  any  characteristic  sign. 


DISEASES  OF  TIIE  ABDOMEN. 


393 


THIRD  BOOK. 

OBSERVATIONS  ON  PERITONITIS. 


SECTION  I. 

ACUTE  PERITONITIS. 

In  the  following  cases  we  shall  endeavour  to  direct  attention  principally  : 1st, 
to  some  of  the  causes  which  must  frequently  give  rise  to  inflammation  of  the 
peritoneum  ; 2dly,  to  the  different  symptoms  which  indicate  the  existence  of 
this  inflammation  ; 3dly,  to  its  progress,  which,  in  certain  cases,  is  so  acute,  that 
not  very  many  hours  intervene  between  the  commencement  of  the  disease  and 
the  patient’s  death,  whilst  at  other  times  its  fatal  termination  does  not  take  place 
till  after  a lapse  of  from  thirty  to  forty  days. 


CHAPTER  1. 

Case  1. — Acute  peritonitis  terminating  in  death. 

A boy,  about  fifteen  years  of  age,  of  a delicate  constitution,  presenting  no 
signs  of  puberty,  a copperplate-printer,  had  been  engaged  at  his  usual  occupa- 
tion on  the  morning  of  the  30th  of  April : he  had  breakfasted  as  usual.  Towards 
two  o’clock  in  the  afternoon,  he  felt  suddenly  in  the  right  flank  a pain  so  severe 
as  to  oblige  him  to  go  to  bed.  In  the  night,  this  pain  extended  to  the  right 
hypochondrium  and  epigastrium  ; vomiting  took  place,  and  the  patient  began  to 
sink  very  rapidly.  These  bad  symptoms  continued  for  the  two  following  days, 
during  which  he  kept  his  bed.  He  drank  nothing  but  sugar  and  water.  On 
May  2d,  we  saw  him  for  the  first  time,  when  he  presented  the  following  state : 

Face  was  pale,  expressive  of  the  most  intense  anxiety,  eyes  dull,  surrounded 
with  a very  marked  bluish  circle  ; intellectual  and  sensorial  faculties  intact ; 
abdomen  tense  and  resisting,  the  slightest  pressure  occasioning  the  most  intoler- 
able pains  over  all  the  right  side  of  the  abdomen  ; no  perceptible  fluctuation. 
Frequent  vomiting  of  a green  bile;  constipation;  tongue  moist  and  whitish  ; 
pulse  of  moderate  frequency,  and  of  ordinary  strength,  and  also  regular ; skin 
hot  and  dry.  (Bleeding  to  twelve  ounces  ; thirty  leeches  over  the  abdomen  ; 
emollient  fomentations  ; flaxseed  lavements,  with  almond-oil,  &c.)  The  blood 
taken  from  the  vein  presented  a large  buflfy  coagulum.  The  pains  were  some- 
what diminished  during  the  day ; at  night  he  enjoyed  a little  sleep. 

Next  day  twenty  more  leeches  to  the  abdomen.  The  vomiting  ceased  in  the 
day.  Next  day,  expression  of  the  face  more  natural ; perceptible  diminution 
of  the  abdominal  pains  ; the  diminished  frequency  of  the  pulse,  the  improvement 
which  the  patient  stated  he  felt,  all  indicated  an  evident  amendment.  Still  the 
tension  of  the  abdomen  continued : the  peritonitis  had  not,  therefore,  been 
resolved  ; but  it  seemed  disposed  to  pass  into  the  chronic  state.  In  the  day,  the 
improvement  still  kept  up  ; the  skin  was  covered  for  the  first  time  with  a gentle 
moisture,  and  soon  with  a profuse  sweat ; this  evacuation,  which  coincide  with 
a perceptible  improvement  of  all  the  symptoms,  might  be  considered  as  a salutary 


394 


ANDUAL’S  MEDICAL  CLINIC. 


critical  movement.  In  the  evening,  the  temperature  which,  had  been  very  high 
all  the  day,  suddenly  fell ; the  wind,  entering  through  the  open  windows,  affected 
the  patient.  The  next  day  he  was  dying  ; the  face  had  undergone,  since  the 
preceding  day,  so  great  a change,  that  one  could  scarcely  recognize  him : all 
the  skin  was  cold ; the  extremities  livid  and  icy  ; pulse  imperceptible  ; the 
respiration,  high  and  hurried,  was  performed  solely  by  the  movement  of  the 
ribs.  Small  quantities  of  bile  were  occasionally  vomited.  Tongue  still  moist ; 
and  the  intelligence  clear  as  ever.  He  died  two  hours  after  the  visit. 

Post-mortem , twenty-two  hours  after  death.  Extremities  still  livid  ; limbs 
rigid  ; ventricles  of  the  brain  contained  a very  small  quantity  of  serum.  The 
right  and  left  cavities  of  the  heart  contained  some  fibrinous,  polypus-like  coagula 
interlaced  between  the  columns  carneae,  and  extending  into  the  different  vessels. 
The  small  intestines  were  distended  with  a great  quantity  of  gas.  The  peri- 
toneum covering  them  was  very  much  injected,  without  a trace  of  any  secre- 
tion. But  on  raising  the  intestines  the  right  flank  and  right  iliac  region  were 
found  to  be  filled  with  a white  liquid  like  milk : this  same  liquid  was  accumu- 
lated in  the  cavity  of  the  pelvis  as  also  in  the  left  flank.  The  two  surfaces  of 
the  stomach,  the  ascending  colon,  the  convolutions  of  the  small  intestines 
contained  in  the  pelvis,  the  convex  surfaces  of  the  liver  and  spleen,  as  well  as 
the  corresponding  portions  of  the  diaphragm,  were  lined  with  whitish  membrani- 
form  concretions,  which  did  not  yet  present  any  trace  of  organisation.  The 
transverse  colon  adhered  to  the  great  curvature  of  the  stomach  by  an  albuminous 
band  of  considerable  consistence. 

The  inner  surface  of  the  stomach  was  white,  except  in  five  or  six  places,  each 
of  which,  on  an  average,  was  the  breadth  of  a ten  sous  piece,  where  there 
appeared  considerable  redness  owing  to  an  agglomeration  of  small  injected  ves- 
sels : every  where  and  even  in  these  red  parts  the  mucous  membrane  was  of  its 
natural  thickness  and  consistence. 

We  have  here  a case  of  acute  peritonitis,  exempt  from  all  complication,  and 
accompanied  with  well-marked  symptoms.  Here  there  was  no  precursor  ; none 
of  those  intermediate  states  between  health  and  disease.  The  first  morbid  phe- 
nomena was  pain  ; at  first  partial,  it  soon  became  general  and  rather  acute,  ac- 
companied with  such  distress  as  to  oblige  the  patient  instantly  to  keep  his 
bed;  this  pain,  moreover,  hacLall  the  characters  which  belong  to  inflammation 
of  the  peritoneum  ; tension  of  the  abdomen  without  perceptible  fluctuation, 
profuse  vomiting  without  any  other  sign  of  the  gastric  mucous  membrane  being 
affected ; that  peculiar  alteration  of  the  features  serve  still  more  to  confirm  the 
diagnosis.  Still,  in  the  midst  of  this  dangerous  state,  the  pulse,  which  was  of 
moderate  frequency  and  of  ordinary  strength,  announced  nothing  alarming  ; one 
would  not  have  found  it  otherwise  in  case  of  a mere  accession  of  fever;  it  was 
far  from  having  that  concentration  and  smallness  said  to  be  characteristic  of 
peritonitis,  and  such  indeed  as  it  is  generally  found  in  this  affection  ; a proof 
among  many  others  that  it  is  never  from  a single  sign  that  any  disease  can  be 
diagnosed.  I think  that  in  such  a case  as  this  all  the  science  of  Bordeu  and 
Fouquet,  with  respect  to  the  pulse,  would  have  been  deceived.  I do  not  mean 
by  this  to  say  that  the  consideration  of  the  arterial  pulsations  is  unimportant ; 
but  I am  disposed  to  think  we  should  not  lose  sight  of  the  fact,  that  the  infor- 
mation furnished  from  this  source,  has  been  on  more  than  one  occasion  alto- 
gether incorrect : this  assertion  is  proved  to  be  true  in  fact ; in  theory  it  must 
hold  equally  good,  since  in  peritonitis,  as  in  every  other  disease,  the  disturbance 
of  the  circulation  is  purely  the  result  of  sympathies,  which  must  vary  to  an  in- 
finite degree  with  respect,  first,  to  their  very  existence,  secondly,  with  respect 
to  their  nature,  and  thirdly,  with  respect  to  their  energy.  Moveover,  observa- 
tion has  taught  us  that  every  inflamed  organ  produces  a special  modification  in 
the  beats  of  the  heart,  both  with  respect  to  their  strength,  their  frequency,  and 


DISEASES  OF  THE  ABDOMEN. 


395 


their  rhythm  ; whence  it  follows  that  each  species  of  inflammation  is  more  fre- 
quently accompanied  with  such  a pulse  than  with  any  other.  Thus  nothing 
can  be  less  alike,  in  most  cases,  than  the  pulse  of  pneumonia  compared  with 
that  of  gastro-enteritis,  or  the  pulse  of  pleuritis  compared  with  the  pulse  of 
peritonitis  ; but  it  is  no  less  true  that  we  should  come  to  extraordinary  miscal- 
culations, if  we  were  not  fully  convinced  that  to  these  general  rules  there  exist 
very  numerous  exceptions. 

When  this  patient  entered  the  Charite,  his  situation  was  very  alarming : under 
the  influence  of  active  antiphlogistic  treatment,  a perceptible  improvement  took 
place.  On  the  sixth  day  the  inflammation  was  not  resolved  ; but  there  was  some 
ground  for  hopes  that  it  would  be  cured  or  would  pass  into  the  chronic  state, 
when,  in  consequence  of  a sudden  interruption  of  the  cutaneous  transpiration, 
which  had  become  very  profuse  since  the  improvement  had  taken  place,  the 
peritonitis  again  became  acute  and  rapidly  carried  off  the  patient.  The  post- 
mortem examination  showed  what  is  ordinarily  found  in  cases  of  recent  perito- 
nitis whose  progress  is  very  acute,  namely,  pus  and  membraniform  concretions 
not  yet  organised.  Now,  who  can  assign  a precise  term  to  the  period  when 
this  organisation  commences  ? There  are  some  cases  where  only  twenty  hours 
after  the  commencement  of  an  inflammation  of  the  peritoneum,  we  have  been 
able  to  trace  and  to  inject  vessels  developed  within  the  fibrinous  concretion 
which  had  become  a living  tissue  : there  are  other  cases,  where,  several  months 
after  the  attack  of  peritonitis,  no  traces  of  organisation  have  been  found  in  the 
membraniform  layers.  No  doubt  there  are  good  reasons  for  these  differences  ; 
no  doubt  the  degree  of  inflammation,  the  nature  of  the  effusion,  several  local  or 
general  conditions  which  escape  us,  exercise  considerable  influence  over  the 
greater  or  less  rapidity  with  which  pseudo-membranes  become  organised  ; but 
certain  as  we  are  that  these  different  effects  imply  the  idea  of  different  causes 
which  produce  them,  we  have  not  yet  attained  the  power  of  determining  these 
causes.  And  yet  till  this  be  determined,  what  shall  we  know  ? Nothing,  but 
that  under  the  influence  of  sanguineous  congestion  variable  in  intensity,  the 
most  different  products  may  be  formed.  But  whence  comes  this  difference  ? 
We  cannot  tell,  at  least  in  the  majority  of  cases,  and  yet  it  is  evident  that  it  is 
a point  which  it  would  be  of  the  utmost  importance  to  ascertain  ; for  the  sole 
consideration  of  the  sanguineous  congestion  leads  us  to  one  single  mode  of 
treatment  merely  directed  to  combat  it,  and  which  like  it,  can  vary  only  in  de- 
gree. Other  therapeutic  views  might  probably  arise  from  the  knowledge  of 
the  causes  under  the  influence  of  which  one  and  the  same  sanguineous  conges- 
tion existing,  there  is  a specific  difference  in  the  products  of  this  congestion. 

Case  2. — A tiler,  eighteen  years  of  age,  with  brown  skin,  chestnut  hair, 
muscles  slightly  developed,  residing  in  Paris  for  the  last  two  years,  was  in  the 
habitual  enjoyment  of  good  health.  On  the  2d  of  March,  without  any  known 
cause,  he  began  to  complain  of  severe  abdominal  pains,  which  continued  on  the 
following  days.  These  pains  were  not  constant,  and  did  not  always  occupy 
the  same  points  of  the  abdomen,  sometimes  affecting  the  entire  of  it,  sometimes 
confined  to  one  or  other  hypochondrium,  or  to  the  flanks,  or  appearing  beneath 
and  around  the  umbilical  region.  He  kept  his  room,  but  not  his  bed,  and 
adopted  no  medical  treatment  for  the  five  following  days,  during  which  time  he 
vomited  frequently.  On  the  morning  of  the  9th  he  entered  the  Charite  and 
presented  the  following  state  : — 

Face  flushed,  though  calm  ; muscular  strength  still  retained  ; abdomen  tense, 
resisting,  without  any  appreciable  alteration,  exhibiting  every  where  an  acute 
sensibility  which  is  increased  by  the  slightest  motion,  or  the  least  contact. 
Posteriorly,  on  both  sides  of  the  vertebral  column,  on  a line  with  the  last  ribs, 
percussion  is  very  painful.  Pulse  small,  very  frequent,  a little  irregular  ; skin 
dry  and  hot there  is  at  the  same  time  a bitter  taste  on  the  mouth,  a yellow 


396 


ANDRAL’S  MEDICAL  CLINIC. 


coating  on  the  tongue,  constipation.  Notwithstanding  the  long  time  which 
had  elapsed  since  the  invasion  of  the  disease,  the  symptoms  of  peritonitis  were 
still  sufficiently  acute  to  warrant  us  in  expecting  to  derive  benefit  from  blood- 
letting. (Thirty  leeches  over  the  abdomen,  two  demi-lavements  of  marshmallow 
root,  with  the  addition  of  half  an  ounce  of  sweet  almonds  in  each  emollient 
fomentation  over  the  abdomen,  oil  mixture,  &c.) 

The  patient  found  considerable  relief  from  the  leeches.  On  the  10th,  abdo- 
men less  tense,  and  much  less  painful.  Pulse  very  small,  and  140.  His  drinks 
had  been  several  times  vomited.  Two  stools.  (Eight  leeches  to  the  anus.) 
On  the  three  days  following  the  vomiting  ceased ; the  abdominal  pains,  which 
moderate  pressure  excited  on  the  11th,  were  no  longer  felt  on  the  12th  on  ap- 
plying equal  pressure.  Pulse  still  frequent ; profuse  diarrhoea  had  now  set  in. 
Eight  leeches  were  applied  to  the  anus  each  of  the  first  two  days.  Still  the 
peritonitis  which  was  no  longer  indicated  by  pain,  was  sufficiently  characterized 
by  the  tension  and  resistance  of  the  abdomen. 

On  the  14th.  Abdomen  tympanitic,  and  again  painful.  Twenty-four  leeches 
over  the  hypogastrium,  and  on  the  next  day  the  pain  as  well  as  the  tympanitic 
state  had  ceased.  Still  the  pulse  was  frequent,  and  the  purging  continued  ; the 
face  was  habitually  red  and  moist.  On  the  14th,  he  desired  to  have  some  rice 
cream.  After  the  visit  he  determined  to  leave  the  hospital,  because  he  thought 
he  was  not  allowed  sufficient  nourishment.  For  this  purpose  he  arose  from 
bed,  dressed  himself,  and  walked  with  a firm  pace  across  the  room.  He  was 
brought  back,  however,  to  his  bed,  and  became  more  resigned.  In  the  evening 
he  began  to  vomit,  and  died  on  the  morning  of  the  17th,  the  fifteenth  day  from 
the  first  appearance  of  the  pains.  We  could  not  ascertain  whether  he  had  pro- 
cured any  food. 

Post-mortem. — The  parietal  and  visceral  peritoneum  were  united  by  close 
adhesions.  The  intestines  were  glued  together  hy  white  thick  membraniform 
layers,  which  as  yet  presented  no  rudiment  of  organisation.  Beneath  them  the 
cellular  tissue  between  the  serous  membrane  and  the  muscular  tunic  of  the 
intestines  presented  a bright  red  injection.  The  pseudo-membranes,  which 
united  the  latter,  enclosed  between  them  spaces,  which  contained  a milk-like 
fluid.  This  liquid  was  in  great  quantity  in  the  pelvis,  in  the  two  flanks,  and 
between  the  superior  surface  of  the  liver  and  diaphragm.  Stomach  distended 
with  gases.  Peyer’s  plexus  appeared  under  the  form  of  black  points  crowded 
together.  The  mucous  membrane  of  the  large  intestine  presented  a great  num- 
ber of  small  black  points,  separated  the  one  from  the  other,  and  surrounded 
with  a slight  elevation  of  the  mucous  membrane. 

In  this  patient  the  peritonitis  had  a different  physiognomy,  if  we  may  be 
allowed  the  term,  from  that  described  in  the  first  case.  In  this  latter  (first  case), 
the  pains  attained  all  at  once  their  maximum  of  intensity,  and  all  at  once  they  were 
accompanied  with  the  most  distressing  symptoms.  In  the  case  now  before  us, 
there  was,  to  be  sure,  simultaneous  with  the  first  pains,  some  vomiting,  but 
the  patient  did  not  keep  his  bed ; if  he  had  fever  at  the  moment  it  was  slight ; 
his  pains  disappeared  at  intervals,  and  when  they  did  return,  it  was  not  always 
in  the  same  points  : by  these  characters  they  might  be  readily  taken  for  what 
are  called  nervous  or  rheumatic  pains,  which,  though  remarkably  severe,  are  not 
in  general  accompanied  by  any  alarming  symptom.  It  must  be  well  known  that 
such  is  the  onset  of  certain  inflammations  of  serous  membranes  ; thus,  in  the  case 
of  arachnitis,  the  headach  often  precedes  all  the  other  symptoms  by  several 
days  ; thus  also,  in  a preceding  part  of  this  work,  we  have  cited  cases  of  pleuritis, 
in  which  at  first  the  patients  had  only  moveable  intermittent  pains  in  several 
points  of  the  thoracic  parietes,  without  these  pains  being  in  the  first  instance 
accompanied  by  cough,  dyspnoea,  or  fever;  but  afterwards  they  became  con- 
stant, and  fixed  to  one  point,  and  then  the  ordinary  symptoms  of  pleuritis  be- 


DISEASES  OF  THE  ABDOMEN. 


397 


came  developed.  When  we  saw  the  patient  the  peritoneal  pain  was  very  severe  ; 
immediately  after  the  application  of  leeches  over  the  abdomen  it  was  lessened, 
and  two  days  after  it  disappeared  altogether,  though  the  other  symptoms  of 
peritonits  still  continued  ; the  appearance  of  profuse  diarrhoea  coincided  with  the 
cessation  of  the  pain.  Still  the  disease  was  far  from  being  cured  ; this  was  one 
of  those  cases  where  there  is  a transition  from  the  acute  to  the  chronic  state  : 
only  this  transition  occurred  more  promptly  than  usual.  This  is  one  of  those  cases 
in  which  we  have  seen  the  peritoneal  pain  disappear  very  rapidly,  after  having 
been  very  intense,  and  without  this  disappearance  being  accompanied  with  any 
perceptible  abatement  of  the  other  symptoms.  Observe  then  with  what  facility 
this  pain  was  again  excited,  which  was  in  a manner  but  lulled  for  a while. 
The  first  time  it  was  relieved  by  the  application  of  leeches;  a second  time, 
this  application  was  not  made  ; the  return  of  the  pain  and  of  the  vomiting 
soon  followed  a strong  mental  *excitement,  and  a momentary  exertion  made 
by  the  patient.  This  new  relapse  carried  him  off,  and  it  would  be  difficult  to 
say  what  was  the  cause  of  death  here,  since  a few  hours  before  he  died  he  pos- 
sessed considerable  strength,  and  the  post-mortem  showed  no  lesion  in  any 
organ  but  in  the  peritoneum  ; the  lungs  in  particular  were  not  even  engorged. 
Thus,  this  individual  passed  without  a struggle  from  life  to  death  amidst  intense 
pains,  indicated  by  the  continual  cries  he  uttered  a few  hours  before  death. 
He  did  not  die  of  exhaustion,  since  a fe\tf  hours  previously  he  was  able  to  put 
on  his  clothes  and  walk. 

We  may  be  satisfied  in  this  case,  that  the  vomiting  which  so  often  accom- 
panies peritonitis  in  its  different  stages,  is  far  from  being  always  connected  with 
gastric  inflammation : for  the  patient  vomited  up  to  the  last  moment,  and  yet 
the  gastric  mucous  membrane  was  found  perfectly  healthy.  See  also  how 
little  marked  was  the  morbid  change  in  the  intestines  (simple  hypertrophy  of 
the  follicles  with  black  colouring  around  them),  though  a profuse  diarrhoea  had 
existed  for  several  days.  To  conclude,  we  may  find  in  the  existence  of  the 
numerous  cells  within  which  the  effused  liquid  was  as  it  were  imprisoned,  a cause 
of  the  obscurity  of  the  fluctuation,  in  more  than  one  case  of  peritonitis,  where,  as 
in  the  case  now  under  consideration,  the  purulent  or  serous  collection  was  still 
rather  considerable.  Here  again  we  find  no  trace  of  organisation  in  the  false 
membranes,  and  yet  the  patient  did  not  die  till  the  seventeenth  day. 

Case  3.  A looking-glass  maker,  nineteen  years  of  age,  had  been  engaged  in 
handling  mercury  during  the  winter  of  1822,  and  he  slept  in  a bed-room  which 
contained  some  ; severe  tremors  soon  affected  his  limbs,  which  ceased,  however, 
when  he  discontinued  his  work.  Still  he  retained  a state  of  general  debility, 
he  had  no  appetite.  On  the  29th  of  June  he  was  seized  without  any  known 
cause  with  acute  abdominal  pains  and  vomiting.  On  the  1st  of  July  he  presented 
the  following  state. 

The  face  pale  and  sharpened,  was  expressive  of  the  most  acute  anxiety : the 
slightest  pressure  occasioned  most  intense  pain  in  the  abdomen  ; abdomen  tense, 
tympanitic  in  the  course  of  the  colon,  without  any  perceptible  fluctuation. 
Tongue  red  and  a little  dry,  great  thirst;  a considerable  quantity  of  green  bile 
had  been  vomited  several  times  during  the  last  twenty-four  hours  ; no  alvine 
evacuation  during  the  last  two  days.  Pulse  frequent  and  small,  skin  dry  and 
hot.  (Venesection  to  sixteen  ounces ; thirty  leeches  over  the  abdomen;  two 
ounces  of  caster  oil  in  divided  doses  ; solution  of  syrup  of  gum  acidulated  with 
lemon  juice,  four  emollient  demi-lavements ; emollient  fomentations  over  the 
abdomen.) 

The  blood  drawn  from  the  vein  collected  into  a large  coagulum  covered  with 
a thin  buffy  coat;  he  again  vomited  some  green  bile  in  the  course  of  the  day, 
and  had  five  or  six  stools. 

On  the  second  the  general  symptoms  were  all  amended,  but  the  pain  and 
34 


398 


ANDRAL’S  MEDICAL  CLINIC. 


tension  of  the  abdomen  still  continued  ; (sixty  leeches  over  the  abdomen  ;)  up 
to  the  day  he  had  nausea,  but  no  vomiting;  after  the  leeches  he  became  very 
much  exhausted  ; pulse,  which  were  hardly  perceptible,  was  now  very  frequent ; 
the  extremities  became  icy  cold  ; and  the  next  morning  his  features  were  entirely 
changed,  he  appeared  to  be  dying  (one  ounce  of  castor-oil,  drinks  and  fomen- 
tations as  before  ; sinapisms  to  the  legs).  In  the  course  of  the  day  his  strength 
rallied,  and  on  the  morning  of  the  4th  of  July  there  was  an  evident  improve- 
ment. A profuse  sweat  in  the  night ; for  the  first  time  he  enjoyed  some  sleep. 
From  the  seventh  to  the  fourteenth  day  the  symptoms  of  acute  peritonitis  seemed 
to  improve  ; from  the  twelfth  day  some  nourishment  was  allowed  (rice-cream)  ; 
from  the  fourteenth  to  the  twenty-fourth  day  the  abdomen  diminished  in  size, 
and  was  nearly  free  from  pain  ; diarrhoea  still  ; on  the  twenty-fifth  day  he  took 
some  panado,  but  vomited  it.  During  the  twelve  first  days  of  August  the  ab- 
domen became  still  more  soft,  and  was  now  frde  from  pain  in  every  part.  This 
individual  reached  the  forty-fifth  day  of  his  peritonitis,  and  every  thing  seemed 
to  announce  a favourable  termination,  when  he  had  the  folly  to  commit  an  error 
in  regimen,  by  eating  a leg  of  a chicken.  Immediately  the  vomiting  and  diar- 
rhoea returned,  and  severe  fever  set  in.  On  the  morning  of  the  forty-sixth  this 
still  continued,  and  at  the  same  time  the  breathing  was  short  and  hurried  ; he 
coughed  without  expectorating,  and  complained  of  smothering.  Still  the  ab- 
domen was  neither  more  tense  nor  more  painful  ; he  now  became  very  much 
exhausted  again.  Percussion  of  the  chest  detected  a diminution  in  its  sono- 
rousness on  the  left  posteriorly,  nearly  over  the  entire  lower  lobe  of  the  lung  of 
this  side ; in  the  same  space  a mixture  of  the  mucous  and  crepitous  rale  was 
heard.  (Venesection  to  twelve  ounces.) 

On  the  two  following  days  the  pectoral  symptoms  improved  ; his  breathing, 
however,  was  evidently  shorter  than  before  his  last  relapse  ; and  besides  aus- 
cultation and  percussion  continued  to  indicate  an  inflammatory  engorgement  of 
a portion  of  the  left  lung.  This  pneumonia  remained  latent  for  the  fifteen  days 
following  (end  of  August).  His  strength  returned  but  in  a slight  degree  ; pulse 
still  frequent;  he  was  evidently  under  the  influence  of  a chronic  inflammation 
with  local  symptoms  not  well  marked.  At  the  commencement  of  September 
he  committed  another  error  in  diet  by  eating  some  bad  figs,  by  which  he  brought 
on  a fit  of  indigestion.  In  sixty-eight  hours  his  countenance  asssumed  a cada- 
veric aspect,  his  extremities  became  cold,  and  he  expired  without  a struggle. 

Post-mortem.  The  intestinal  convolutions  were  united  by  false  membranes, 
several  of  which  had  already  a cellular  appearance  ; numerous  vessels  were  now 
seen  to  ramify  over  them  ; others,  which  were  softer,  and  seemed  to  be  of  more 
recent  formation,  covered  the  convex  surface  of  the  liver  ; the  flanks  and  cavity 
•of  the  pelvis  were  filled  with  thick  pus.  Within  four  or  five  fingers’  breadth 
of  the  ileo-caecal  valve  there  were  four  broad  ulcerations,  with  white  bottom, 
consisting  of  cellular  tissue,  and  with  edges  a little  brownish,  oh  a level  with  the 
bottom.  Another  ulceration  of  the  same  appearance,  the  breadth  of  a thirty- 
sous  piece,  was  found  immediately  below  the  ileo-caecal  valve.  The  lower  lobe 
of  the  left  lung  was  impervious  to  air,  and  presented  a mixture  of  red  and  grey 
induration. 

The  disease  which  forms  the  subject  of  this  case  presents  four  periods  for  our 
consideration  : 1st,  that  during  which  the  peritonitis  commenced  and  proceeded 
in  an  acute  form  ; 2dly,  the  period  of  the  transition  of  this  inflammation  to  a chronic 
state;  3dly,  another  period,  during  which  all  the  symptoms  of  peritonitis  appa- 
rently leave  the  patient ; 4thly,  the  last  period,  from  the  commencement  of  the 
pneumonia  to  the  death  of  the  individual. 

In  the  first  period  we  have  to  remark  the  sudden  invasion  of  the  abdominal 
pain,  which  suddenly  acquired  its  greatest  intensity  ; the  vomitings  which  here 
coincided  with  the  red  and  dry  tongue,  a circumstance  which  was  not  observed 


DISEASES  OF  THE  ABDOMEN. 


399 


ill  the  two  preceding  cases ; the  gradual  improvement  of  the  symptoms  under 
the  influence  of  copious  bloodletting  ; the  state  of  debility,  apparently  very  great, 
into  which  the  patient  fell  after  the  second  of  these  bleedings,  but  which  soon  dis- 
appeared, and  was  followed  by  a perceptible  amendment  both  in  the  local  and 
general  symptoms  of  the  peritonitis. 

In  the  second  period  we  see  the  vomitings  cease,  the  pains  disappear,  but  the 
abdomen  retain  a degree  of  tension,  still  indicating  the  existence  of  the  peritoneal 
inflammation.  A fact,  which  seems  of  some  importance,  is  the  facility  with  which, 
in  consequence  of  a very  slight  increase  in  the  patient’s  usual  diet,  the  peritonitis 
repassed  for  a moment  into  the  acute  state. 

Afterwards,  the  tension  of  the  abdomen  also  disappeared  ; every  thing  seemed 
to  announce  a resolution  of  the  peritonitis  ; yet  the  post-mortem  examination, 
which  took  place  long  after  this,  proved  the  existence  of  serious  alterations  in  the 
peritoneum  ; namely,  pus  effused  in  different  points  of  the  cavity  of  this  mem- 
brane. With  respect  to  the  cellular  adhesions,  they  indicated  the  cure  of  the 
inflammation  ; we  found  similar  adhesions  in  persons  who  several  years  before 
had  had  all  the  symptoms  of  an  acute  peritonitis,  from  which  they  recovered, 
and  at  the  time  we  saw  them  they  did  not  complain  of  any  pain  in  the  abdomen. 
If  besides,  these  adhesions  were  very  numerous  — if  they  intimately  united  all 
the  intestinal  convolutions,  we  can  readily  conceive  that  the  result  might  be,  on 
the  one  hand,  some  modification  in  the  form  of  the  abdomen,  habitual  tension 
of  the  abdominal  cavity,  and  on  the  other  hand,  more  or  less  disturbance  of  the 
digestive  functions.  Be  that  as  it  may,  from  the  case  now  under  consideration, 
we  shall  draw  this  consequence,  that  when  in  an  acute  or  chronic  inflammation 
of  the  peritoneum  all  the  local  symptoms  have  disappeared,  the  morbid  change 
of  the  peritoneum  has  not  for  that  reason  completely  ceased  to  exist  in  all  cases  ; 
this  is  applicable  moreover  to  inflammations  of  all  organs  ; there  are  few  of  them 
in  which  pathological  anatomy  has  not  proved  that  a residue  of  lesion  may  sur 
vive  the  local  symptoms  which  announced  it.  What  happens  then  ? Mostfre- 
quently  in  the  absence  of  these  symptoms,  the  suffering  organ  continues  to  ex- 
ercise a mischievous  influence  either  on  the  circulation,  whence  more  or  less 
fever  is  kept  up,  or  on  the  function  of  nutrition,  whence  the  strength  and  flesh 
are  prevented  from  returning.  However,  as  every  acute  symptom  has  disap- 
peared, the  individual  is  considered  to  be  in  a state  of  convalescence  ; but  such 
is  far  from  being  the  case,  and  then  the  slightest  deviation  in  diet,  the  least  im- 
prudence, occasions  a relapse,  which  is  but  the  rekindling  of  an  inflammation, 
which  was  only  quenched  a little,  but  not  entirely  extinguished. 

This  deviation  in  regimen  actually  took  place  in  our  patient ; but  what  was 
very  remarkable,  it  was  not  the  organ  primarily  affected  that  felt  its  pernicious 
influence  ; thus  the  symptoms  of  peritonitis  did  not  reappear.  It  was  not  even 
the  intestinal  mucous  membrane  that  was  affected  ; but  all  the  signs  of  acute 
pneumonia  were  seen  to  appear,  which  itself  soon  passed  into  the  chronic  state, 
and  which,  without  the  aid  of  auscultation  and  percussion,  one  would  consider 
cured,  as  well  as  the  peritonitis. 

In  this  state  of  things,  wherein  several  organs  were  found  at  one  and  the  same 
time  in  a state  of  chronic  inflammation,  the  least  unusual  shock  given  to  the 
system,  the  least  violence  offered  to  this  machine  already  deranged  in  several 
points,  is  sufficient  to  destroy  it,  by  arresting  probably  the  action  of  the  nervous 
system,  the  functions  of  which  had  been  for  a long  time  perverted.  How  else 
are  we  to  account  for  the  manner  in  which  this  patient  died  after  another  devia- 
tion in  regimen,  and  that  without  the  symptoms  of  the  triple  affection  of  the 
lung,  intestine,  and  peritoneum,  being  perceived  to  have  been  in  the  slightest 
degree  aggravated  ? 

We  cannot  conclude  these  reflections,  without  remarking  the  ulcerations  which 
were  found  towards  the  termination  of  the  small  intestine,  and  which  were  con- 


400 


ANDRAL*S  MEDICAL  CLINIC. 


nected  with  a diarrhoea  of  long  standing,  whicli  had  ceased  only  at  intervals. 
Compare  now  the  state  of  the  intestine  in  this  patient,  and  in  the  preceding,  who 
also  had  diarrhoea  : the  mode  of  alteration  is  very  different. 

Case  4. — Peritonitis  by  external  violence. 

A middle-aged  man,  of  a strong  constitution,  had  received  a kick  of  a horse  in 
the  abdomen,  near  the  umbilical  region  ; no  solution  of  continuity  had  been  oc- 
casioned ; a large  ecchymosis  was  produced  on  and  around  the  part  struck  ; the 
patient  instantly  vomited  several  times,  and  about  three  hours  after  the  accident, 
he  felt  very  acute  pains  in  the  abdomen.  In  two  days  after  he  entered  the 
Charite,  presenting  all  the  symptoms  of  acute  peritonitis  ; abdomen  tense,  tym- 
panitic along  the  course  of  the  colon,  so  painful  that  the  weight  of  the  bedclothes 
could  not  be  borne ; very  frequent  vomiting  of  green  bile ; constipation  ; face 
pale,  and  features  sharpened  ; pulse  very  frequent  and  weak  ; skin  not  hot.  The 
exhausted  state  of  the  patient  prohibited  general  bleeding  ; thirty  leeches  were 
applied  over  the  abdomen,  two  blisters  to  the  legs,  emollient  lavements  and 
fomentations.  In  the  twenty-four  hours  following  no  improvement  took  place, 
and  he  died  on  the  fifth  day. 

Post-mortem.  Blackish,  half-coagulated  blood  effused  between  the  fibres  of 
the  muscles  of  the  abdominal  parietes.  The  peritoneum  covering  these  parietes 
was  raised  by  this  blood  and  coloured  by  it  on  its  external  surface  ; the  cavity 
of  the  peritoneum  was  filled  with  a liquid  resembling  whey  not  clarified,  in  the 
midst  of  which  whitish  fiocculi  floated,  several  of  which  extended  in  layers  over 
a great  number  of  intestinal  convolutions,  over  the  ascending  and  descending 
colon,  in  the  stomach  and  liver.  In  five  or  six  places  of  these  membraniform 
excretions  some  red  points,  very  distinct,  were  observed,  and  in  other  parts 
some  reddish  lines.  Beneath  the  pseudo-membrane  the  peritoneum  presented 
considerable  injection,  the  seat  of  which  appeared  to  be  the  cellular  tissue  situate 
beneath  it.  Kidneys  remarkably  pale. 

This  case  is  remarkable  for  the  cause  which  produced  the  peritonitis,  for  the 
rapid  succession  of  the  symptoms,  and  for  the  promptly  fatal  termination  of  the 
disease.  Here  there  was  no  complication  ; the  several  phenomena  and  death 
were  solely  the  result  of  the  inflammation  of  the  peritoneum,  or,  to  speak  more 
correctly,  of  the  sympathetic  disturbance  occasioned  by  this  inflammation  in 
the  nervous  system  ; thence,  the  sudden  sinking  of  the  strength,  the  secession 
of  the  blood  from  the  cutaneous  capillaries,  the  suspension  of  the  function  of 
calorification,  the  weakness  of  the  pulsations  of  the  heart,  which,  at  the  same 
time  that  they  diminish  in  strength,  become  more  and  more  frequent.  Thus, 
then,  it  is  not  solely  on  the  rapidity  of  the  circulation  that  the  production  of  the 
heat  of  the  skin  depends.  It  is,  moreover,  only  in  a certain  order  of  their 
functions  that  the  nervous  centres  are  modified  ; for  up  to  the  last  moment  no 
disturbance  was  observed  in  the  intellectual  and  sensorial  faculties  ; neither  did 
the  lungs  present,  up  to  the  last  moment,  any  disturbance  in  the  performance  of 
their  functions  ; so  that  the  respiration,  without  having  been  first  altered,  with- 
out any  intermediate  change  between  the  healthy  and  morbid  state,  became  extinct 
all  at  once  with  the  pulsations  of  the  heart;  and  life  thus  disappeared,  without  our 
finding  any  appreciable  change  in  the  organs,  the  sound  state  of  which  should 
be,  one  would  suppose,  a sufficient  guarantee  for  its  continuance. 

We  have  already  remarked,  in  one  of  the  preceding  cases,  the  total  absence  of 
organization  in  false  membranes,  found  in  a case  of  peritonitis  of  considerably 
long  standing.  Here,  on  the  contrary,  where  the  attack  of  inflammation  was  of 
a much  more  recent  date,  the  red  points  and  lines  found  within  several  mem- 
braniform concretions  were  evidence  of  a process  of  organisation  which  was 
beginning  to  take  place : this  fact  seems  to  me,  moreover,  to  prove  beyond  all 
question,  that  the  red  part  of  the  blood  may  form  even  in  the  midst  of  the  false 


DISEASES  OF  THE  ABDOMEN. 


401 


membranes,  and  that  it  is  not  necessarily  brought  to  them  by  vessels  from  the 
serous  membrane  continued  into  the  false  membrane. 

Case  5. — Peritonitis,  the  attack  of  which  coincided  with  the  disappearance  of  articular  rheu- 
matism— Red  effusion  into  the  peritoneum — Malformation  of  the  bladder. 

A man,  fifty-seven  years  of  age,  labouring  under  an  incontinence  of  urine  of 
long  standing,  and  having  had  purging  at  intervals,  had  acute  articular  rheuma- 
tism with  fever,  when  he  entered  the  Charite,  the  beginning  of  November. 
Several  of  the  joints  became  swollen  and  painful.  In  a day  or  two  the  swelling 
and  pain  of  the  joints  ceased  all  at  once,  when,  for  the  first  time,  acute  pains 
were  felt  in  the  abdomen  : this  became  very  severe  ; pressure  did  not  increase 
nor  lessen  them.  The  face  became  pale  and  expressive  of  the  greatest  anxiety  ; 
pulse  very  frequent  and  hard ; this  is  what  the  old  physicians  used  to  call 
rheumatic  metastasis.  The  principal  indication  seemed  to  be  to  recall  the  irri- 
tation to  its  primary  seat.  Every  means  were  resorted  to  in  order  to  effect  this, 
but  without  avail.  The  abdominal  pains  spread  over  all  the  parts  of  the  abdo- 
men and  became  extremely  acute  ; the  slightest  pressure  now  aggravated  them. 
The  abdomen  became  very  much  enlarged,  and  there  was  evident  fluctuation. 
There  was  some  nausea  without  vomiting.  He  died  before  the  termination  of 
the  third  day  from  the  commencement  of  the  attack. 

Post-mortem.  Scarcely  was  an  incision  made  into  the  abdominal  parietes, 
when  an  immense  quantity  of  a red  fluid  escaped  through  the  opening,  in  the 
midst  of  which  some  white  flocculi  floated.  The  intestines  were  coloured  red, 
and  on  the  surface  of  several  of  the  convolutions,  membraniform  concretions  of 
a red  colour  were  deposited.  The  liquid  in  the  peritoneum  resembled  blood 
drawn  from  a vein  ; no  coagulum  was  observed  in  it,  nor  was  any  large  vessel 
found  to  be  opened.  The  follicles  of  the  end  of  the  small  intestine,  caecum,  and 
commencement  of  the  colon  were  enlarged  ; these  follicles  were  bounded  by  a 
black  circle;  a black  point  was  also  observed  in  their  centre.  The  summit  of 
the  bladder  was  surmounted  by  a large  oval  pouch,  which  extended  behind  the 
packet  of  the  small  intestines,  and  adhered  by  its  upper  extremity  to  the  third 
portion  of  the  duodenum.  This  adhesion  was  evidently  of  recent  formation. 
This  pouch  internally  resembled  the  bladder,  and  in  its  parietes  we  could  easily 
trace  the  different  tunics  ordinarily  found  in  the  bladder;  its  muscular  fibres, 
however,  tvere  but  little  developed,  and  intermixed  with  much  cellular  tissue. 
This  sort  of  supernumerary  bladder  communicated  with  the  natural  bladder  by 
an  aperture  which  was  contracted  by  a thick  ridge  formed  by  the  mucous  mem- 
brane, and  particularly  by  condensed  cellular  tissue.  To  the  right  of  this  open- 
ing, another  small  pouch  was  found,  capable  of  containing  a nut,  which  also 
communicated  with  the  normal  bladder ;.  it  was  separated  from  the  great  pouch 
by  a partition  which  projected  into  its  cavity. 

In  the  preceding  parts  of  this  work  I cited  cases  of  pneumonia,  pleuritis, 
pericarditis,  the  commencement  of  which  coincided  with  the  disappearance  of 
acute  rheumatic  affections  ; here  we  have  a similar  phenomenon,  an  attack  of 
peritonitis  succeeding  to  rheumatism.  It  matters  but  little  whether  we  call  this 
displacement  of  the  disease  metastasis  or  otherwise,  provided  the  fact  is  not 
forgotten  that  the  abrupt  disappearance  of  rheumatism  is  often  connected  with 
the  development  of  an  internal  inflammation,  which,  by  reason  of  individual 
predisposition,  attacks  such  or  such  an  organ,  principally  serous  membranes. 
The  first  day  the  abdominal  pains  were  felt  by  our  patient,  they  resembled  what 
is  commonly  called  rheumatism  fixed  on  the  intestines  : what  was  particularly 
remarkable  in  these  pains  was,  that  pressure  did  not  increase  them  ; and  in  this 
state  of  things,  it  was  not  certain  that  there  was  peritonitis,  and  the  prognosis 
was  not  yet  decidedly  bad.  It  is  quite  certain,  that  in  many  eases  where,  as 
here,  acute  and  violent  pains  are  suddenly  felt  in  the  abdomen,  in  persons  either 
34* 


402 


ANDRAL’S  MEDICAL  CLINIC. 


at  the  time  labouring  or  who  formerly  laboured  under  rheumatism,  these  pains 
disappear  more  or  less  promptly,  without  leaving  behind  them  any  trace  of  dis- 
ease ; and  then  it  is  at  least  doubtful,  whether  they  are  the  result  of  peritoneal 
inflammation.  But  in  the  patient  who  forms  the  subject  of  the  present  case,  it 
was  not  so  ; and  from  the  second  day  of  the  appearance  of  these  pains,  the 
existence  of  peritonitis  could  not  longer  be  called  in  doubt : fluctuation  was  felt 
in  the  abdomen,  and  the  evidence  of  this  fluctuation  was  itself  a remarkable  cir- 
cumstance ; for  it  generally  happens  that  during  the  first  days  of  the  existence 
of  peritonitis,  the  abdominal  effusions  being  but  inconsiderable,  may  be  rather 
recognised  by  the  tension  and  resistance  of  the  parietes,  the  change  in  the  form 
of  the  abdomen,  than  by  any  great  increase  in  its  size,  or  by  the  existence  of 
fluctuation.  Here  it  was  otherwise,  and  the  nature  of  the  liquid  found  in  the 
peritoneum  sufficiently  accounted  for  it.  This  liquid  was  blood,  or  at  least 
serum  united  with  the  colouring  matter  of  the  blood,  which  in  a very  short  space 
of  time  had  been  exhaled  in  an  enormous  quantity  on  the  internal  surface  of  the 
serous  membrane  ; there  were,  moreover,  flocculi  and  false  membranes,  which 
showed  that  this  kind  of  hemorrhage  was  connected  with  an  inflammatory  state 
of  the  peritoneum.  This  is  one  of  the  most  acute  cases  of  peritonitis,  without 
the  existence  of  intestinal  perforation,  which  we  have  ever  seen.  Scarcely 
three  days  elapsed  between  the  invasion  of  the  abdominal  pains  and  the  death 
of  the  individual  ; and  still  here,  also,  we  find  no  appreciable  lesion  of  any  of 
the  organs  important  to  life,  such  as  the  heart,  lungs,  or  nervous  centres. 

Case  6. — Peritonitis  consecutive  on  acute  metritis  in  a woman  recently  delivered. 

A woman,  thirty-one  years  of  age,  was  delivered  naturally,  but  with  much 
difficulty  and  pain,  of  her  first  child,  the  beginning  of  December.  Four  days 
after  she  was  seized,  without  any  knowi^cause,  with  violent  fever  and  some  pain 
in  hypogastrium.  The  same  evening  she  entered  the  Charite,and  was  very  weak 
and  much  dejected.  About  three  fingers’  breadth  above  the  pubis  we  found  a 
globular  tumour  painful  on  pressure,  which,  in  its  form  and  position,  resembled 
the  body  of  the  uterus.  The  hypogastric  pain  the  patient  stated  was  less  than 
that  which  she  felt  in  the  groins.  No  discharge  from  the  vagina  ; pulse  fre- 
quent and  hard  ; tongue  natural ; skin  hot  and  dry.  The  case  was  announced 
to  be  acute  metritis,  for  which  leeches  and  the  ordinary  treatment  were  pre- 
scribed. Between  the  third  and  seventh  day  general  bleeding  was  employed  ^ 
leeches  were  twice  applied  ; the  fever  diminished ; the  inguinal  and  hypogas- 
tric pain  ceased,  but  the  tumour  still  continued.  She  was  sinking  rapidly  ; great 
alteration  of  the  features.  On  the  eighth  day  vomiting  set  in  ; she  vomited 
green  bile,  and  her  ptisan.  The  pain  over  the  entire  abdomen  was  aggravated 
by  the  slightest  touch  ; still  the  abdomen  was  not  tense  : suppression  of  the 
alvine  and  urinary  evacuations.  About  forty  hours  after  these  new  symptoms 
she  expired. 

Post-mortem. — A turbid  milky  serum  was  effused  in  some  quantity  into  the 
peritoneum,  which  was  here  and  there  covered  with  whitish  membraniform 
spots,  without  any  trace  of  true  organisation  ; there  was  observed  considerable 
injection,  the  seat  of  which  seemed  to  be  the  subperitoneal  cellular  tissue.  The 
latter  was  partially  filled  in  several  points  with  reddish  serum.  More  flocculi 
and  a thicker  liquid  than  that  contained  in  the  rest  of  the  peritoneal  cavity  of 
the  pelvis.  The  tumour  observed  during  life  still  projected  above  the  pubis, 
and  found  to  be  the  uterus  enlarged.  The  tissue  of  this  organ  was  become  very 
friable,  and  was  very  easily  torn  ; when  an  incision  was  made  into  its  parietes, 
a large  quantity  of  creamy  pus  gushed  from  every  part  of  the  organ,  particularly 
from  its  fundus.  The  cavity  of  the  uterus  was  very  large  and  its  surface  red. 
Two  remarkable  lesions  were  found  in  the  thoracic  organs.  1st.  A tuberculated 
state  of  the  bronchial  glands,  which  were  very  large.  2d.  At  the  apex  of  the 


DISEASES  OF  THE  ABDOMEN. 


403 


left  lung  a small  cavity,  with  cellulo-fibrous  parietes,  capable  of  admitting  a 
cherry,  and  communicating  by  a species  of  anfractuous  fistulae  with  two  other 
cavities  of  still  smaller  dimensions,  all  containing  a small  quantity  of  reddish 
liquid  ; the  pulmonary  tissue  around  these  was  black  and  hard ; when  viewed 
externally  it  was  puckered,  and  was  separated  from  the  first  rib  by  a sort  of 
half-cartilaginous  membrane  several  lines  thick,  evident  of  old  false  membranes 
of  the  pleurae. 

This  case  is  remarkable  in  more  respects  than  one.  First  it  presented  a 
striking  instance  of  acute  metritis,  coming  on  without  any  known  cause,  after 
a first  confinement  in  a young  woman.  After  active  antiphlogistic  treatment 
the  symptoms  improved  ; and  one  would  have  supposed  that  the  inflammation 
of  the  uterus  was  progressing  towards  resolution,  if  the  size  of  the  tumour 
formed  by  this  organ  had  not  remained  the  same.  On  the  other  hand  the  rapid 
sinking  of  the  patient  indicated  the  continuance  of  a serious  lesion,  What  was 
very  remarkable  and  deserving  the  attention  of  every  practitioner  was,  that  at 
the  very  time  when  the  fever  was  becoming  almost  none,  and  the  hypogastric 
and  inguinal  pain  was  disappearing,  the  uterus  was  becoming  disorganised,  its 
tissue  was  filling  with  pus,  and  towards  the  tenth  day  since  the  invasion  of  the 
metritis,  this  pus  was  already  forming  several  abscesses.  It  is  not  uncommon 
to  see  the  formation  of  pus  in  different  organs  with  a marked  remission  of  the 
worst  symptoms  ; this,  for  instance,  has  been  more  than  once  observed  in  the 
brain.  What  attaches  still  further  interest  to  the  present  case,  is  the  rapidity 
with  which  the  suppuration  set  in  ; the  disease  was  chronic  in  several  of  its 
symptoms,  and  acute  in  its  progress. 

The  peritonitis  may  be  considered  as  having  its  point  of  departure  in  the 
portion  of  the  serous  membrane  in  the  vicinity  of  the  uterus.  The  copious 
bloodletting  employed,  state  of  debility  of  the  patient,  the  acute  marasmus  with 
which  she  was  struck,  did  not  prevent  the  development  of  this  new  inflamma- 
tory process,  which  appeared  to  extend  from  the  tissue  of  the  uterus  by  con- 
tiguity of  tissue,  to  its  investing  membrane,  and  thence  to  the  rest  of  the  perito- 
neum. One  may  say,  generalising  this  particular  case,  that  the  circumstance 
of  one  organ  being  inflamed  is  a reason  for  others  becoming  so  ; so  that  in  most 
acute,  but  principally  in  chronic  diseases,  it  is  extremely  rare  to  find  but  one 
organ  affected.  However,  in  this  same  case,  a remarkable  exception  to  what 
has  now  been  stated  presents  itself,  an  exception  which,  in  the  case  of  perito- 
nitis, is  almost  constant ; we  mean  the  continuance  of  the  healthy  state  of  the 
gastro-intestinal  mucous  membrane,  notwithstanding  the  very  acute  inflamma- 
tion of  the  peritoneum. 

The  signs  of  peritonitis  were  manifest ; one  only  was  wanting,  namely, 
tension  of  the  abdomen  ; but  the  continuance  of  the  soft  state  of  the  abdominal 
parietes  is  an  ordinary  case  in  women  seized  with  peritonitis  after  delivery ; 
the  reason  of  it  is  evident.  The  alteration  observed  at  the  apex  of  the  left  lung 
I consider  to  indicate  a cicatrisation  of  tuberculous  cavities.  This  fact  acquires 
considerable  importance  here,  in  consequence  of  the  tubercles  which  existed  in 
the  bronchial  glands  ; it  is  a proof  in  favour  of  the  opinion  of  M.  Louis,  who 
thinks  that  every  time  any  organ  whatever  contains  tubercles  the  lung  also  con- 
tains some. 

Case  7. — Acute  peritonitis  coming  on  during  a chronic  enteritis— Effvlsion  of  reddish  serum 
into  the  peritoneum,  without  any  other  trace  of  inflammation  of  this  membrane. 

A stonecutter,  fifty-four  years  of  age,  who  had  been  several  times  treated  at 
the  Charite  for  metallic  colic,  had  been  labouring  under  severe  purging  for  the 
last  four  months.  When  he  entered  the  hospital  he  was  weak  and  very  much 
emaciated,  there  were  nine  or  ten  stools  every  twenty-four  hours.  Tongue 
natural ; loss  of  appetite  ; abdomen  soft,  and  painful  only  at  intervals,  generally 


404 


ANDliAL’S  MEDICAL  CLINIC. 


before  going  to  stool.  (Sydenham’s  white  decoction  ; gum  potion  ; starch 
lavement,  with  two  drops  of  Rousseau’s  laudanum  and  yolk  of  egg.)  The  next 
day  but  four  stools.  For  the  three  following  days  the  same  treatment  was 
adopted.  Only  three  stools  per  day.  On  the  24th  some  decoction  of  catechu 
was  added.  Only  two  stools  up  to  the  following  morning  ; abdomen  free  from 
pain ; no  fever.  The  same  medicine,  and  the  same  state  of  the  patient,  up  to 
the  28th.  Two  stools  per  day  without  pain.  M.  Lerminier  now  substituted 
for  the  other  medicines  the  decoction  of  simarouba.  The  patient  continued  this 
treatment,  from  the  first  to  the  6th  of  March.  But  one  stool  in  the  twenty-four 
hours.  Abdomen  free  from  pain ; still  the  patient  recovered  neither  strength 
nor  appetite.  On  the  6tli  everything  changed  ; tongue  red  and  dry,.  (Sima- 
rouba suspended  : emollient  ptisans.)  On  the  10th,  fever  gone  ; tongue  moist 
and  pale  ; purging  returned.  Simarouba  again  presented.  On  the  12th,  purging 
stopped.  On  the  15th,  simarouba  suspended.  Everything  seemed  to  promise 
a recovery : yet  the  countenance  continued  very  pale.  No  return  of  appetite 
or  of  the  strength  ; a little  fever  observable  particularly  towards  the  evening. 
On  the  16th,  a great  change  took  place  in  the  state  of  the  patient;  extreme 
anxiety;  acute  abdominal  pains,  which  were  increased  by  the  least  pressure; 
pulse  very  small  and  frequent;  skin  very  hot.  Peritonitis  was  now  present 
beyond  all  doubt.  (Twenty  leeches  to  the  abdomen.)  Abdominal  pains  less 
the  following  day  ; tumefaction  of  the  abdomen,  which  presents  an  obscure 
fluctuation.  From  the  11th  to  the  24th,  the  abdominal  pains  ceased  to  be  felt; 
the  fluctuation  became  more  and  more  manifest ; and  considerable  ascites  soon 
appeared.  The  pulse  was  feeble,  but  not  frequent ; two  liquid  stools  took 
place  in  the  twenty-four  hours.  (Blister  to  the  legs  ; simple  emollients  inter- 
nally.) On  the  25th,  the  abdominal  pain  reappeared  ; extreme  prostration  ; all 
the  symptoms  of  approaching  death  set  in,  which  took  place  on  the  26th. 

Post-mortem. — An  abundance  of  reddish  serum  in  the  peritoneum,  without 
an  admixture  of  other  flocculi,  or  any  trace  of  false  membranes,  or  any  appear- 
ance  of  any  inflammatory  process  whatever  in  the  serous  membrane,  or  in  the* 
subjacent  cellular  tissue. 

On  the  lower  fourth  of  the  small  intestine  a considerable  number  of  ulcerations 
were  observed,  the  bottoms  of  which  were  brownish,  and  consisted  of  cellular 
tissue,  hard  and  thickened  ; in  several  of  them  the  bottom  was  on  a level  with 
the  edges,  and  the  tissue  forming  them  appeared  continuous  with  the  mucous 
membrane.  Was  this  commencing  cicatrisation  ? Between  these  ulcerations, 
and  even  on  their  edges,  the  mucous  membrane  was  white  and  very  consistent. 

The  acute  peritonitis  in  this  case  cannot  be  called  in  question,  from  the  symp- 
toms which  indicated  it  during  life  ; from  the  mere  inspection  of  the  dead  body 
it  might  have  been  overlooked.  For  we  find  no  other  change  in  the  peritoneum 
except  an  effusion  of  serum  combined  with  a certain  quantity  of  the  colouring 
matter  of  the  blood.  This  is  what  is  observed  in  certain  cases  of  simple 
ascites  consecutive  on  a mechanical  obstacle,  and  supervening  without  pain. 
Here  then  is  a case  wherein  the  nature  of  the  symptoms  throws  more  light  on 
the  real  nature  of  the  disease  than  is  done  by  pathological  anatomy  ; compare 
this  case  with  those  where,  though  no  pain  existed  during  life,  pus,  false  mem- 
branes, etc.,  are  found  in  the  peritoneum. 

Another  disease  was  present  in  this  individual  at  the  time  of  his  admission, 
namely,  chronic  inflammation  of  the  intestinal  mucous  membrane  ; we  should 
at  least  consider  the  diarrhoea  under  which  this  patient  laboured  for  so  long  a 
time  as  being  the  result  of  this  inflammation.  We  first  gave  simple  emollients, 
narcotics,  and  then  astringent  tonics.  During  the  administration  of  these  medi- 
cines we  observe  the  purging  disappear  no  doubt,  but  only  for  a time.  The 
stomach  became  irritated,  as  appeared  from  the  redness  of  the  tongue  and  the 
fever.  This  gastritis,  which  was  probably  occasioned  by  the  simarouba,  was 


DISEASES  OF  THE  ABDOMEN. 


405 


soon  removed  by  suspending  the  use  of  this  medicine.  Then  the  purging 
reappeared  ; the  astringent  bark  was  again  resumed,  and  it  stopped  it,  nor  did 
it  afterwards  return. 

From  the  influence  exercised  at  first  by  the  tonic  treatment  on  the  cessation 
of  the  diarrhoea,  one  would  naturally  be  disposed  to  think  that  this  diarrhoea 
was  not  here  connected  with  an  intestinal  inflammation,  but  that  it  depended 
rather  on  a state  of  atony  of  the  mucous  membrane,  that  it  was  a species  of 
passive  Jinx.  The  post-mortem  examination  proved  that  this  was  not  the  case. 
Over  a certain  extent  of  the  intestine  ulcerations  were  found  to  exist,  which 
their  appearance  showed  to  be  of  long  standing;  but  the  absence  of  colour  in 
the  mucous  membrane  between  them,  indicates  the  absence  of  any  previous 
reaction  on  the  part  of  the  ulcerations.  This  is  the  strict  expression  of  the 
facts.  If  we  now  wish  to  deduce  any  consequence  from  them,  we  shall  ask 
whether  such  a case  does  not  seem  to  afford  a proof  that  there  are  certain 
chronic  inflammations  which  may  be  beneficially  combated  by  others  means 
than  those  that  are  simple  antiphlogistics.  We  have  already  discussed  this 
point  of  doctrine.  Observe  further,  that  it  cannot  be  said  in  this  case  that  the 
cessation  of  the  purging  was  the  result  of  the  increase  of  the  irritation  of  the 
intestinal  mucous  membrane : for  if  it  had  been  so,  we  should  have  seen  the 
abdominal  pain  become  aggravated  and  fever  set  in ; in  a word,  we  should  have 
observed  that  group  of  symptoms  which  manifest  themselves  when  a chronic 
inflammation  passes  for  a time  into  the  acute  state.  But  it  was  not  so.  We 
may  ask,  however,  whether  the  irritation  in  the  stomach,  after  the  employment 
of  the  astringents,  did  not  perform  a part  in  the  temporary  disappearance  of  the 
diarrhoea.  Neither  shall  we  forget  that  even  after  the  purging  stopped,  the  con- 
tinuance of  the  anorexia  and  of  the  general  debility,  as  also  the  febrile  move- 
ment, indicated  an  organic  lesion  which  survived  the  diarrhoea.  In  this  case  we 
found  an  additional  instance  of  a diarrhoea  in  which  the  cause  of  the  intestinal 
flux  resided  solely  in  the  small  intestine,  the  large  intestine  having  been  found 
perfectly  healthy.  We  may  remark  that  the  total  anorexia  which  this  patient 
experienced  for  a long  time  back  could  not  be  accounted  for  by  any  appreciable 
alteration  of  the  stomach  itself,  which  appeared  to  have  suffered  merely  tem- 
porary irritation,  at  the  time  when  the  tongue  became  red  and  the  fever  increased. 


CHAPTER  II. 

ACUTE  PERITONITIS  CURED. 

Case  8. — Acute  peritonitis,  the  first  symptoms  of  which  showed  themselves 
during  the  paroxysm  of  an  intermittent  of  the  tertian  type.  He  had  had  already 
five  paroxysms,  which  presented  nothing  unusual,  and  during  the  intermissions 
he  was  in  good  health,  when  at  the  commencement  of  the  cold  stage  of  the 
sixth  paroxysm  he  felt  acute  pains  in  the  abdomen,  which  were  increased  by 
pressure  and  by  motion.  These  pains  continued  during  the  cold  and  hot  stage, 
and  disappeared  according  as  the  sweating  stage  set  in.  Till  the  return  of  the 
next  paroxysm  these  pains  did  not  reappear;  pressure  on  the  abdomen  did  not 
excite  them,  but  the  patient  was  pale  and  more  cast  down  than  usual.  The 
pain  reappeared  with  the  cold  stage  of  the  seventh  paroxysm,  but  disappeared 
with  the  sweat  as  at  first.  Till  then  the  intermittent  fever  had  been  left  to 
itself.  After  the  seventh  paroxysm  we  began  to  give  the  sulphate  of  quinine 
in  ten-grain  doses.  At  the  usual  time  the  shivering  reappeared  with  the  abdo- 
minal pain  ; there  were  also  two  attacks  of  bilious  vomiting.  After  having 
lasted  only  an  hour,  it  ceased ; but  was  not  succeeded  either  by  a hot  stage 


406 


ANDRAL’S  MEDICAL  CLINIC. 


similar  to  that  of  the  preceding  paroxysms,  nor  by  sweat  ; other  symptoms 
much  more  ^alarming  appeared  ; the  abdominal  pain  continued  to  be  very  acute  ; 
the  abdomen  became  tense  ; bilious  vomiting  came  on  every  half  hour,  small 
at  first,  but  very  distressing  to  the  patient.  The  face  became  shrivelled  and 
pale,  and  the  pulse  very  frequent.  On  the  next  morning  there  was  no  doubt 
of  the  patient  been  attacked  with  peritonitis.  Leeches  were  ordered,  and  as 
there  was  constipation  castor  oil  also  was  given  in  small  and  repeated  doses. 
The  leech  bites  continued  to  bleed  all  the  day;  he  had  five  or  six  bilious  stools. 
The  next  day  the  abdominal  pains  were  felt  only  on  pressing  or  moving,  but 
then  they  were  very  acute  ; he  could  lie  only  on  his  back.  Some  nausea  still, 
but  no  vomiting.  Abdomen  full  and  tense.  Leeches  applied  every  day  for  the 
three  days  following,  and  a blister  to  each  leg.  He  was  now  in  the  sixth  day 
of  his  peritonitis,  and  the  pain  had  been  decreasing  every  day,  as  also  the  fre- 
quency of  the  pulse.  The  skin,  which  was  till  now  dry,  was  covered  with  a pro- 
fuse sweat.  On  the  10th  day  he  was  convalescent. 

We  may  here  observe  the  evident  success  of  the  treatment  employed.  For 
four  days  an  almost  constant  bleeding  was  kept  up  on  the  abdominal  parietes, 
and  before  this  a general  bleeding  had  been  adopted.  The  castor  oil  seemed  to 
be  very  serviceable,  and  lastly,  the  blisters  applied  to  the  lower  extremities,  at 
a time  when  the  inflammatory  symptoms  were  much  less  acute,  affected  a 
useful  revulsion,  and  accelerated,  no  doubt,  the  complete  resolution  of  the 
peritonitis.  Irritants  applied  to  the  skin  as  revulsives  have  certainly  been  very 
much  abused  ; when  employed  too-  soon,  or  with  persons  of  very  irritable  habit, 
or  with  very  active  sympathies,  they  have  but  too  often  aggravated  the  inflam- 
mation which  they  were  intended  to  subdue.  Instances  of  their  danger  occur 
in  several  parts  of  this  work.  But  in  many  cases  their  great  advantage  cannot 
be  called  in  question.  It  will  be  seen  that  in  general  blisters,  applied  to  the 
lower  extremities,  at  a distance  from  the  seat  of  the  disease,  have  appeared  to 
succeed  best. 

Thus  in  cases  of  pleuritis,  pneumonia,  and  pericarditis,  it  is  to  different  parts  of 
the  lower  extremities  that  we  should  apply  revulsives,  though  there  may  be  cases 
in  which  their  application  to  the  chest  itself  will  be  more  useful.  In  cases  of  acute 
cerebral  affection,  the  application  of  a revulsive  to  the  nucha  has  scarcely  ever 
appeared  to  be  attended  with  advantage  ; with  respect  to  blisters  to  the  cranium, 
they  have  always  seemed  to  have  an  injurious  influence.  On  one  occasion  in  a 
child  who  presented  several  symptoms  of  arachnitis,  I observed  a perceptible 
improvement  on  the  day  following  the  application  of  the  blister.  This  was 
attributed  to  the  action  of  the  revulsive,  when,  on  raising  it,  we  found  that  the 
skin  of  the  cranium  had  been  but  slightly  reddened,  but  no  blister  had  been 
raised.  I once  saw  a large  blister  applied  over  the  abdominal  parietes  of  a per- 
son labouring  under  acute  peritonitis,  and  a very  marked  exasperation  of  the 
symptoms  followed.  ' With  respect  to  inflammations  of  the  gastro-intestinal 
mucous  membrane,  the  application  of  blisters  over  the  abdomen  in  their  acute 
state  aggravates  them  in  general ; yet  there  are  some  exceptions  to  this  ; thus 
we  have  several  times  seen  very  profuse  alvine  evacuations,  which  came  on  sud- 
denly, were  accompanied  with  very  little  fever,  and  soon  exhausted  the  patient 
very  much,  arrested  by  the  application  of  a large  blister  to  the  abdomen.  This 
same  mode  of  treatment  also  is  sometimes  very  efficacious  in  soon  arresting 
-chronic  diarrhoea. 

If  this  case  is  interesting  with  respect  to  the  favourable  termination  of  the 
disease,  it  is  no  less  deserving  of  attention  with  respect  to  the  onset  of  the  pro- 
gress of  the  peritonitis.  Its  first  symptoms  were  intermittent,  like  those  of  the 
paroxysm  of  tfie  tertian  ague,  in  the  middle  of  which  they  appeared.  No  doubt, 
during  the  cold  stage,  severe  sanguineous  congestion  took  place  in  the  perito- 
neum, and  disappeared  as  soon  as  the  sweat  announced  the  recall  of  the  fluids 


DISEASES  OF  THE  ABDOMEN. 


407 


from  the  interior  to  the  exterior.  Was  there  this  first  time  simple  congestion 
in  the  peritoneum,  or  real  inflammation  of  this  membrane?  the  decision  of 
this  point  appears  to  me  of  little  importance,  as  I conceive  these  two  states 
always  tend  to  become  confounded  by  imperceptible  shades,  as  one  may  satisfy 
oneself  by  observing  the  different  degrees  of  ophthalmia.  The  same  symptoms 
of  peritonitis  uniformly  reappeared  in  the  succeeding  paroxysm  ; they  were  still 
more  marked  than  the  first  time,  since  they  were  accompanied  by  vomiting.  It 
is  probable  that  if  the  sulphate  of  quinine  had  been  able  to  prevent  the  return  of 
the  following  paroxysms,  the  peritonitis  would  have  been  removed  with  them  ; 
but  such  was  not  the  case,  and  probably  the  quinquina  was  ineffectual  for  this 
very  reason,  that  there  was  a predisposition  in  the  system  to  a more  serious 
disease ; a new  paroxysm  reappeared  with  symptoms  of  peritonitis  ; here,  how- 
ever (and  this  was  different  from  what  we  have  observed  at  other  times),  the 
irritation  of  the  peritoneum,  whether  it  was  more  intense,  or  of  a different  nature, 
did  not  disappear  ; sweating  did  not  terminate  the  paroxysm  of  fever,  and  it  did 
not  reappear  till  eight  days  afterwards  : again  coinciding  with  the  favourable 
termination  of  the  peritonitis.  Then  it  announced  its  complete  resolution,  as, 
in  the  two  last  well  defined  paroxysms  of  intermittent  fever,  it  had  marked  the 
termination  of  the  abdominal  pains.  Here  then  is  a striking  instance  of  san- 
guineous congestion  at  first  intermittent,  like  the  febrile  paroxysms  with  which 
it  coincided,  and  replacing  these  paroxysms  as  soon  as  ever  it  became  continued. 
Perhaps  at  the  time  of  the  third  paroxysm,  of  which  the  first  stage  only  was 
observed,  if  an  attempt  had  been  made  to  produce  a powerful  congestion  towards 
the  skin,  either  by  a hot  bath,  by  stimulant  fumigations,  or  by  various  revul- 
sives, we  might  have  established  the  movement  from  the  centre  to  the  surface, 
and  by  exciting  sweat,  we  might  have  cut  short  the  peritonitis  by  producing 
artificially  that  which  had  been  done  by  nature  in  the  two  preceding  paroxysms. 
The  quinquina  then  might  have  been  administered  anew  for  the  purpose  of  pre- 
venting the  return  of  the  following  paroxysms.  In  a preceding  part  of  this  work 
I have  cited  a case  of  pleuritis,  the  symptoms  of  which  at  first  appeared  only 
every  evening.  These  facts  seem  to  me  to  prove  the  possibility  of  intermittent 
inflammations ; the  fact  is  undeniable  with  respect  to  several  cutaneous  inflam- 
mations. There  is  at  this  moment  in  the  hospital  Saint  Louis,  under  the  care 
of  Dr.  Biett,  an  individual  who,  for  the  last  two  years,  has  had  his  skin  covered 
every  evening  with  an  eruption,  of  which  there  is  not  a trace  to  be  seen  in  the 
morning.  This  periodical  affection  has  not  yielded  to  quinquina.  Two  classes 
of  these  intermittent  inflammations  must  be  distinguished  ; some  of  them  occur 
as  mere  complications  during  a paroxysm  of  fever  ; they  are  the  result  of  a 
local  congestion  more  intense  than  ordinary,  and  produce  symptoms  more  or  less 
serious,  which  disappear  with  the  paroxysm  ; thence  result  those  diseases  called 
pernicious  fevers.  The  disease  now  under  consideration,  Torti  would  have 
called  peritoneal  intermittent  fever.  Other  inflammations  also  occur  in  an 
intermittent  form,  but  isolated  and  separate,  without  being  preceded  or  accom- 
panied by  shivering,  or  followed  by  sweating ; in  a word,  without  that  group  of 
symptoms  which  constitute  a paroxysm  of  fever. 


SECTION  II. 

CHRONIC  PERITONITIS. 

It  is  only  by  collecting  and  carefully  perusing  cases  that  one  can  make  himself 
acquainted  with  the  infinitely  varying  forms  which  chronic  inflammation  of  the 
peritoneum  may  assume.  They  are  cases,  no  doubt,  where  nearly  the  same 


408 


ANDRAL’S  MEDICAL  CLINIC. 


symptoms  are  observed  as  those  which  mark  the  existence  of  acute  peritonitis'; 
but  at  otherNtimes  these  symptoms  disappear  : thus,  there  are  cases  of  chronic 
peritonitis  which  are  painful  only  at  their  onset ; there  are  others  which  never 
occasion  the  slightest  pain,  resembling  in  this  respect  certain  cases  of  pleuritis, 
already  alluded  to  in  a preceding  part  of  this  work,  which  commence,  become 
developed,  and  terminate  in  the  formation  of  vast  purulent  collections,  without 
the  patient’s  having  ever  felt  any  pain.  There  are  other  cases  of  chronic  peri- 
tonitis in  which  the  abdomen  retains  its  softness  ; and  if  there  be  at  the  same 
time  no  pain,  the  inflammation  of  the  peritoneum  must  be  almost  necessarily 
overlooked.  In  certain  cases  the  onset  of  the  disease  has  been  peritonitis  ; but 
at  a subsequent  period  nothing  is  found  but  mere  ascites.  Owing  to  the  varying 
disposition  of  false  membranes,  the  abdominal  parietes  may  present  strange 
anomalies  in  their  form  ; the  fever  may  be  continued,  may  exist  only  at  inter- 
vals, or  may  not  appear  at  all ; chronic  peritonitis  again  is  found  very  much 
modified  in  its  progress  and  in  its  symptoms  by  the  different  diseases  which 
may  complicate  it,  and  which  have  their  seat  either  in  the  abdomen,  such  as 
different  affections  of  the  digestive  tube  or  liver,  or  outside  this  cavity,  as  diseases 
of  the  lungs  or  their  appendages.  In  the  peritoneum,  affected  with  chronic 
inflammation,  different  accidental  productions  are  frequently  developed,  and 
particularly  tubercles  ; in  this  organ,  better  than  in  any  other,  can  we  trace  the 
formation  of  those  bodies,  ascend  to  their  etiology,  and  discover  their  nature. 
The  different  forms  of  chronic  peritonitis  being  determined,  it  still  remains  to 
be  ascertained  what  treatment  is  most  applicable  to  them,  and  how  this  treat- 
ment should  be  modified  according  to  circumstances. 


CHAPTER  I. 

CASES  OP  CHRONIC  PERITONITIS  ACUTE  AT  THEIR  ONSET. 

Case  9 * — Very  acute  abdominal  pain  and  frequent  vomiting  during  the  first  ten  days  ; after- 
wards, a disappearance  of  every  sign  of  acute  inflammation  of  the  peritoneum — Collection 
of  pus  in  the  cavity  of  this  membrane — Chronic  entero-colitis. 

A woman,  forty-four  years  of  age,  felt,  on  the  2 1st  of  March,  an  acute  pain, 
which,  taking  its  origin  at  the  hypogastrium,  extended  into  the  inguinal  region. 
She  then  had  nausea  and  vomiting.  The  application  of  leeches  relieved  her. 
Pressure,  however,  still  excited  pain  in  the  abdomen,  which  still  was  tense  ; no 
return  of  strength.  She  remained  in  this  state  till  the  16th  of  May,  when  her 
state  was  as  follows  : — flesh  flabby  and  pale  ; marasmus  ; great  debility  ; fea- 
tures drawn,  and  expressive  of  pain  ; abdomen  enlarged,  but  soft ; its  parietes 
were  so  flaccid  that  fluctuation  could  not  be  perceived;  painful  only  when  pres- 
sure was  made  on  the  hypogastrium  and  flanks  ; tongue  pale,  and  covered  with 
a dirty  yellowish  coat ; her  ptisans  excited  nausea  and  vomiting  ; great  thirst; 
no  appetite  ; profuse  diarrhoea  for  the  last  six  weeks  ; pulse  frequent  and  weak  ; 
skin  hot  and  dry.  All  means  for  stopping  the  diarrhoea  failed,  and  she  died 
June  the  1st. 

Post-mortem.  The  peritoneum  was  filled  with  a brownish,  sanious  liquid, 
which  separated  the  intestines  from  the  abdominal  parietes.  Several  of  the 
intestinal  convolutions  were  found  to  have  formed  adhesions.  Numerous  ulcer- 
ations were  found  on  the  termination  of  the  small  intestine  and  caecum. 

When  this  patient  entered  the  Charite  the  symptoms  of  enteritis  were  much 

* This  case  of  chronic  peritonitis,  and  the  following,  were  acute  at  their  commencement. 


DISEASES  OF  THE  ABDOMEN. 


409 


more  marked  than  those  of  peritonitis.  The  abdomen  did  not  present  that 
tension  and  resistance  usually  observed  when  the  peritoneum  is  inflamed. 
On  the  contrary,  it  presented  that  flaccid  appearance  met  with  in  persons  who 
have  passed  from  a state  of  considerable  embonpoint  to  that  of  great  emaciation. 
Still  the  previous  history,  and  the  pain  still  occasioned  by  pressure,  induced 
M.  Lerminier  to  think  that  the  inflammation  of  the  serous  membrane,  by  which 
the  disease  seemed  to  have  commenced,  was  continued  into  the  chronic  state. 
The  correctness  of  this  diagnosis  was  confirmed  by  the  autopsy.  It  was  so 
much  more  the  difficult,  as  the  wasting  of  the  patient,  and  the  hectic  fever  which 
consumed  her,  were  sufficiently  accounted  for  by  the  existence  of  the  chronic 
diarrhoea.  It  was  one  of  those  varieties  of  peritonitis  which  approach  so  very 
closely  to  ascites  in  their  symptoms.  The  brownish  colour  of  the  liquid  which 
filled  the  serous  membrane  is  also  deserving  of  our  attention : it  bore  the 
greatest  resemblance  to  the  liquid  which  often  fills  the  ileum.  It  was  even  our 
opinion,  at  first,  that  there  had  been  perforation  of  this  intestine,  either  at  the 
last  moments  of  life,  or  even  at  the  time  when  the  abdomen  was  opened,  in  con- 
sequence of  handling  the  ulcerated  portions  of  the  intestine.  Yet  no  solution  of 
continuity  was  observed.  A very  active  antiphlogistic  treatment  may  some- 
times arrest  the  progress  of  an  acute  peritonitis,  and  rescue  the  patient  from 
death,  but  then  the  inflammation  too  often  passes  into  the  chronic  state  ; and 
if  the  patient  no  longer  complains  of  pain,  if  the  abdomen  is  not  very  tense,  the 
practitioner  may  at  first  fancy  that  a complete  cure  has  taken  place,  but  he  will 
be  cruelly  undeceived  when  he  finds  that  the  patient’s  strength  does  not  return, 
that  some  fever  still  continues,  and  that  convalescence  is  prolonged  to  an  inde- 
finite period. 

Case  10. — Abdominal  pains  at  the  onset ; afterwards  abdomen  completely  indolent — Tension 
of  the  abdominal  parietes — Soldering  ( soudure ) of  the  intestinal  convolutions  appreciable  by 
manual  examination  through  the  abdominal  parietes — Purulent  effusions  in  separate  com- 
partments in  the  peritoneum — Rectitis. 

A woman,  twenty  years  of  age,  who  had  been  delivered  of  her  first  child  a 
year  before  entering  the  hospital,  was  in  very  good  health,  when  one  day,  on 
leaving  her  bed,  she  felt  an  acute  pain  in  the  right  flank,  which  was  relieved, 
but  not  removed,  by  the  application  of  leeches.  For  the  following  twelve  days 
this  pain  was  rather  obscure,  but  at  the  end  of  this  time  the  abdomen  was  tume- 
fied and  painful.  She  entered  the  Charite  March  21st,  when  thirty  leeches 
were  immediately  applied,  which  removed  the  pain.  The  next  morning  the 
abdomen  continued  tumefied,  but  free  from  pain,  except  in  the  hypogastric  re- 
gion, where  pressure  caused  pain.  Vomiting  for  the  last  three  days  ; tongue 
natural  ; constipation  ; pulse  very  frequent  and  contracted  ; skin  not  hot.  The 
usual  remedies  were  resorted  to,  such  as  leeches,  demulcent  lavements,  castor- 
oil,  &c.  From  the  23d  to  the  28th,  abdomen  free  from  pain,  but  it  became 
harder,  and  very  tense  and  knobby  ( [bossele ).  On  examining  with  the  hand, 
we  thought  we  felt  the  intestines  soldered  together,  and  forming  but  a single 
mass.  Pulse  frequent  and  weak  ; a little  diarrhoea.  From  the  1st  to  the  22d 
of  April,  the  peritoneal  symptoms  remained  the  same,  but  severe  diarrhoea  set 
in.  The  patient  sunk  imperceptibly,  and  towards  the  end  of  April  the  respira- 
tion became  embarrassed,  and  she  died. 

Post-mortem.  Intestines  united  by  numerous  small  cellular  bands,  the  latter 
circumscribing  purulent  effusions,  so  as  to  form,  as  it  were,  separate  abscesses, 
the  partitions  of  these  abscesses  were  of  a dark  red  colour  ; the  cavity  of  the 
pelvis,  the  right  iliac  fossa,  and  the  left  flank,  were  filled  with  greenish  pus.  To 
the  left  of  the  uterus  a purulent  pouch  was  found  large  enough  to  hold  an  orange. 
The  gastric  mucous  membrane  was  soft,  and  streaked  with  reddish  lines  in  its 
35 


410 


ANDRAL’S  MEDICAL  CLINIC. 


splenic  portion.  The  mucous  membrane  of  the  rectum  presented  several  red 
patches.  , 

Three  periods  presented  themselves  in  this  disease  with  respect  to  the  symp- 
toms of  peritonitis.  At  first  we  observed  some  pain,  which  was  not  accom- 
panied by  any  morbid  phenomenon,  and  which  did  not  appear  to  indicate  any 
thing  serious  ; it  was  just  such  a pain,  for  instance,  as  oftentimes  precedes  the 
appearance  of  the  menses  in  women.  This  symptom,  however,  light  as  it  ap- 
peared, was,  as  it  were,  the  precursor  of  the  most  serious  phenomena.  This 
pain,  which  appeared  not  connected  with  any  thing  particular,  which  was  not 
so  severe  as  to  prevent  her  from  attending  to  her  usual  occupation,  became 
changed,  after  a certain  time,  into  a pain  which  assumed  all  the  characters  of 
peritoneal  pains,  and  it  was  only  then  the  other  symptoms  of  acute  peritonitis 
became  developed.  These  symptoms  soon  disappeared  after  a large  bleeding, 
and  then  commenced  the  third  period,  when  the  disease  of  the  peritoneum  be- 
came chronic.  It  alone  was  no  doubt  sufficient  to  carry  the  patient  to  the 
grave ; but  her  death  was  further  accelerated  by  the  profuse  diarrhoea  which  set 
in.  The  organic  change  which  kept  up  this  was  confined  to  the  rectum.  The 
lesions  found  in  the  peritoneum  attest  the  chronic  form  of  the  inflammation  of 
this  membrane.  We  may  remark  those  numerous  bands,  formed  of  a dense  cel- 
lular tissue,  which  was  already  organised,  though  the  disease  was  not  yet  of  a 
very  long  standing.  Those  numerous  abscesses  are  also  deserving  our  notice, 
the  parietes  of  which  consisted  of  cellular  bands.  The  numerous  septa  which 
confined  the  pus  in  so  many  distinct  cells  rendered  it  quite  impossible  to  per- 
ceive the  fluctuation. 


CHAPTER  IL 

CASES  OF  PERITONITIS  CHRONIC  FROM  THEIR  ONSET. 

Case  11. — Ascites  coming  on  without  pain — (Edema  of  the  limbs — Turbid  flocculent  serum 
in  the  peritoneum — Scirrhus  of  the  stomach  and  colon. 

A man,  sixty  years  of  age,  began  to  feel  some  disturbance  in  the  functions  of 
digestion  two  years  before  entering  the  Charite  ; he  had  never  felt  any  pain  in 
the  epigastrium,  and  about  seven  months  before  the  period  we  saw  him,  he 
began  to  vomit.  When  we  saw  him,  he  was  in  a state  of  marasmus;  face  very 
pale  ; most  of  the  food  which  he  took  was  vomited  a few  hours  after  being 
taken.  Complete  anorexia;  much  acrid  eructation;  tongue  covered  with  a 
thick  yellowish  coat ; obstinate  constipation.  Leeches  were  applied  to  the 
epigastrium,  with  some  benefit.  Some  days  after  a moxa  was  placed  on  it. 
The  gastric  symptoms  at  first  improved.  The  vomiting  was  diminished,  but 
the  abdomen  soon  began  to  swell,  and  peritoneal  effusion  became  manifest. 
About  a month  after  the  ascites,  the  lower  extremities  became  cedematous ; no 
fever.  He  became  weaker  every  day,  passed  but  little  urine,  never  perspired  ; 
tongue,  which  fora  long  time  had  a^healthy  appearance,  became  red  and  dry  ; 
pulse  frequent  and  very  small ; an  adynamic  state  set  in,  and  he  died.  The 
abdomen  had  never  been  painful. 

Post-mortem.  Turbid  serum  in  the  peritoneum,  containing  albuminous  floc- 
culi,  which  were  found  in  great  quantity  towards  the  left  hypochondrium. 
Gastric  mucous  membrane  injected  towards  the  great  cul-de-sac  ; two  fingers’ 
breadth  on  this  side  of  the  pylorus  this  membrane  no  longer  existed.  The 
ulcer  resulting  from  this  was  formed  of  thickened  and  indurated  cellular  tissue 
(scirrhus).  The  muscular  coat  of  this  part  had  also  disappeared.  The  pylorus 


DISEASES  OF  THE  ABDOMEN. 


411 


was  very  much  contracted,  and  could  not  admit  the  end  of  the  little  finger. 
About  three  inches  in  length  and  one  in  breadth  of  the  mucous  membrane  of  the 
transverse  colon  was  puckered.  Beneath  it  the  cellular  tissue  presented  a 
scirrhous  appearance,  like  that  of  the  pylorus. 

The  lesions  found  in  the  dead  body  leave  no  doubt  that  peritonitis  existed  in 
this  case.  Still  this  inflammation  was  not  announced  by  any  pain  either  at  its 
onset  or  in  its  course  ; everything  inclined  one  to  think  that  the  tumefaction  of 
the  abdomen  was  the  result  of  simple,  or  what  is  called  essential  ascites.  This 
peritonitis  thus  free  from  pain  supervened,  as  a complication  towards  the  latter 
period  of  the  affection  of  the  stomach  ; this  latter,  which  was  essentially  chronic, 
repassed  into  the  acute  state  a few  days  before  the  patient’s  death.  With  this 
acute  state,  the  intense  redness  of  the  gastric  mucous  membrane  was  connected, 
and  also  the  sudden  change  of  the  appearance  of  the  tongue,  which,  having  been 
natural  till  then,  became  red  and  dry.  At  the  same  time  that  this  symptom  of 
acute  gastritis  became  developed,  the  prostration  made  rapid  progress  ; and  the 
adynamic  state,  in  which  the  patient  died,  appeared  in  this  case  to  be  the  result 
of  the  acute  inflammation  of  the  stomach,  supervening  on  a chronic  disease  of 
this  viscus. 


SECTION  III. 

PARTIAL  PERITONITIS. 

I have  elsewhere  spoken  of  partial  inflammation  of  the  pleura,  and  we  have 
seen  how  much  the  symptoms  of  this  form  of  inflammation  of  the  thoracic  serous 
membrane  differ  in  certain  respects  from  those  of  general  pleuritis,  and  how  im- 
portant it  is  to  obtain  a correct  knowledge  of  them.  The  same  reflections  apply 
to  partial  peritonitis.  Though  common  enough,  particularly  in  the  chronic  state, 
they  have  hitherto  been  but  very  superficially  studied ; and  yet  what  can  be 
more  deserving  of  attention  than  the  different  groups  of  symptoms,  whether 
local  or  general,  to  which  they  give  rise  ? what  more  delicate  than  their  dia- 
gnosis in  many  instances  ? There  are  cases  of  peritonitis,  which,  from  their  deep 
seat,  are  announced  only  by  pain,  acute  or  dull,  continued  or  intermittent,  with- 
out the  presence  of  any  tumour  appreciable  during  life,  without  any  change  in 
the  form  of  the  abdominal  parietes,  or  diminution  of  their  natural  softness. 
Other  cases  of  partial  peritonitis  compress,  displace,  and  irritate  the  organs  in 
the  vicinity  of  the  portion  of  inflamed  peritoneum,  and  the  most  prominent 
morbid  phenomenon  to  which  they  give  rise,  is  a greater  or  less  disturbance  in 
the  functions  of  these  organs,  so  that  one  supposes  the  latter  to  be  affected, 
whilst  their  investing  membrane  alone  is  diseased.  At  other  times,  in  conse- 
quence of  their  more  superficial  seat,  circumscribed  peritoneal  inflammations 
produce  tumours  appreciable  to  the  sight  and  touch.  These  tumours,  which 
vary  infinitely  in  their  situation,  form,  size,  and  relations,  are  often  considered 
as  appertaining  to  the  different  organs  which  they  happen  to  be  nearest.  The 
mistake  is  particularly  liable  to  be  committed  when  the  functions  of  these  organs 
are  at  the  same  time  more  or  less  disturbed.  With  respect  to  the  general  symp- 
toms, they  are  not  at  all  constant.  Thus  the  fever  may  be  none,  intermittent 
or  continued  ; nutrition  may  remain  intact,  or  become  deteriorated,  and  thus 
"marasmus  supervene.  In  many  of  these  cases  of  partial  peritonitis,  the  local 
symptoms  are  the  least  marked  ; there  is  neither  pain  nor  tumour,  nor  marked 
disturbance  in  the  functions  of  the  different  abdominal  viscera.  But  the  indi- 
viduals waste  away,  they  feel  an  habitual  illness  and  indisposition,  for  which 


412 


ANDRAL’S  MEDICAL  CLINIC. 


they  cannot  account ; paroxysms  of  fever  supervene ; as  in  every  sick  person, 
the  nervous  system  becomes  sensitive;  we  observe  in  the  functions  of  this 
system  several  anomalies,  which  we  cannot  account  for.  It  is  then  that  the 
primary  cause  of  all  these  symptoms  is  referred  to  this  same  nervous  system, 
whilst  in  reality  it  is  affected  only  sympathetically,  and  altogether  secondarily. 
How  many  such  diseases,  a long  time  considered  as  mere  neuroses,  then  become 
serious  organic  diseases  ! They  were  so  from  the  commencement  ; but,  on 
account  of  the  absence  of  the  local  symptoms,  their  nature  must  unavoidably  be 
mistaken.  Such  is  the  case  with  several  hypochondriacs.  Their  sufferings 
are  considered  imaginary,  and  still  it  is  true  that,  in  the  greater  part  of  these, 
the  strange  phenomena  observed,  and  which  are  very  properly  referred  to  dis- 
turbance of  the  nervous  functions,  have  their  point  of  departure  in  a more  or 
less  latent  affection  of  some  organ.  That  minute  attention  which  they  pay  to 
their  health,  that  extraordinary  tendency  to  exaggerate  every  the  least  suffering, 
is  it  not  a mode  of  giving  expression,  as  one  may  say,  to  the  habitual  indispo- 
tion  which  they  experience,  which  is  but  too  real,  and  which  we  are  always 
disposed  to  deny,  because  we  cannot  discover  the  cause  ? The  partial  inflam- 
mations may  attack  the  following  structures  : 1st,  The  great  epiploon  ; 2d,  The 
peritoneum  of  the  hypochondria  and  flanks;  3d,  That  of  the  cavity  of  the 
pelvis. 


CHAPTER  I. 

EPIPLOITE. 

Case  12. — Acute  epiploitis  causing  death  in  an  individual  labouring  under  a chronic  affection 

of  the  stomach  and  liver. 

A man,  sixty-four  years  old,  entered  the  Charite  in  the  middle  of  January. 
He  presented  the  symptoms  of  chronic  gastritis,  and  moreover  the  liver  passed 
several  fingers’  breadth  below  the  cartilaginous  edge  of  the  ribs  of  the  right  side, 
and  formed  a tumour  in  the  hypochondrium  painful  to  the  touch.  He  remained 
in  this  way  till  February  17,  constantly  becoming  weaker  ; on  this  day  he  had 
some  vomiting  and  an  acute  pain  over  the  anterior  wall  of  the  abdomen.  On 
the  18th,  pain  continued  ; the  recti  muscles  were  very  tense  and  contracted. 
He  died  on  the  22d. 

Post-mortem.  The  abdominal  parietes  being  raised,  we  found  extended  in 
front  of  the  intestines  a reddish  body  five  or  six  lines  in  thickness,  readily  torn, 
and  then  allowing  a sero-sanguinolent  fluid  to  ooze  from  it ; it  was  attached 
superiorly  to  the  transverse  colon,  terminating  inferiorly  in  a free  edge,  not  far 
from  the  pubis,  its  lateral  edges  being  equally  free.  This  body  was  evidently 
the  great  epiploon  reddened  and  swollen  by  acute  inflammation,  which  had  been 
announced  by  the  ordinary  symptoms  of  every  acute  inflammation.  Cancerous 
masses  were  found  in  the  liver,  and  scirrhous  induration  of  the  walls  of  the  sto- 
mach in  its  pyloric  portion.  The  mucous  membrane  also  was  thickened  and 
of  a slate  colour. 

In  another  case  I saw  a considerable  tumour  developed  in  twenty-four  hours 
around  the  umbilicus  in  a person  affected,  as  in  this  case,  with  disease  of  the 
liver ; he  also  died  rapidly.  On  opening  the  body,  we  found  that  the  tumour 
detected  during  life  was  formed  by  the  epiploon,  considerably  swollen,  and  dis- 
charging, when  torn,  a bloody  fluid.  The  numerous  alterations  of  which  the 
great  epiploon  may  become  the  seat,  may  have  their  origin  in  an  acute  inflam- 
mation like  the  preceding-;  but  in  several  cases  it  is  never  in  an  acute  form,  but 


DISEASES  OF  THE  ABDOMEN. 


413 


gradually  and  imperceptibly,  that  these  changes  are  produced.  Thus  we  may 
find  it  either  merely  tumefied  and  gorged  with  liquid,  or  really  hypertrophied, 
or  indurated  and  scirrhous,  or  transformed  into  fibrous  tissue.  In  its  interior, 
and  with  one  or  other  of  the  preceding  alterations,  either  pus  may  be  secreted, 
and  scattered  through  it,  or  collected  into  an  abscess  or  tuberculous  matter.  The 
adipose  vesicles,  which  it  contains  in  great  numbers,  may  present  themselves 
under  the  form  of  small  hard  granulations,  which  seem  to  be  fat  modified  in 
some  way,  as  we  may  satisfy  ourselves  by  examining  the  successive  grades 
through  which  it  passes,  in  order  to  take  on  the  appearance  of  these  granula- 
tions, which  are  again  one  of  those  lesions  very  vaguely  designated  by  the  name 
of  cancer. 

According  as  it  is  developed,  undergoing  one  or  more  of  the  alterations  now 
mentioned,  the  great  epiploon  may  be  modified  in  its  form,  so  as  to  constitute 
tumours  varying  in  every  way  with  respect  to  their  size  and  appearance.  These 
tumours  may  be  often  readily  taken  for  the  stomach,  the  parietes  of  which  are 
thickened  and  indurated  ; this  happens  principally  when  the  great  epiploon 
increases  in  size,  and  forms  a tumour  only  in  the  part  which  extends  from  the 
great  curvature  of  the  stomach  to  the  colon.  It  then  often  represents  a sort  of 
puffy  tumour  (bourrelet),  of  more  or  less  thickness,  which  throws  back  the  arch 
of  the  colon,  and  borders  the  stomach.  When  felt  through  the  abdominal  pari- 
etes, this  puffy  tumour,  with  a smooth  or  uneven  surface,  must  be  taken  for  the 
stomach  ; according  to  the  degrees  of  development  of  the  gastro-colic  epiploon, 
manual  examination  may  induce  us  to  think  that  the  stomach  itself  forms  a 
tumour,  either  through  the  entire  of  its  body,  or  in  the  great  cul-de-sac,  or  in  its 
pyloric  portion.  In  such  cases  I have  seen  the  mistake  become  so  much  the 
more  inevitable,  as  with  this  tumour  there  co-existed  symptoms  of  an  organic 
affection  of  the  stomach.  At  other  times,  on  the  contrary,  digestion  continues  to 
go  on,  and  then  these  tumours  of  the  gastro-colic  epiploon  may  continue  for  a 
very  long  time,  without  perceptibly  disturbing  the  system.  At  other  times  again, 
without  there  being  any  disturbance  of  the  digestion,  the  morbid  state  of  the 
epiploon  reacts  sympathetically  on  other  organs,  modifies  the  circulation,  and  by 
itself  produces  the  hectic  fever  and  death.  All  these  differences  depend,  no 
doubt,  1st,  on  the  relations  of  the  tumour  to  the  stomach  ; 2dly,  on  its  anatomical 
composition  ; 3dly,  on  the  individual  predisposition  of  the  patient,  whence  are 
produced  functional  disturbances  of  the  most  varying  description  under  the 
influence  of  one  and  the  same  lesion.  If  the  great  epiploon  be  tumefied  principally 
on  its  left  portion,  the  tumour  which  it  forms  may  then  resemble  the  enlarged 
spleen  in  its  situation,  its  direction,  and  its  relations. 


CHAPTER  II. 

PARTIAL  INFLAMMATION  OF  THE  PERITONEUM,  FLANKS,  AND  HYPO- 
CHONDRIA. 

Cellular  bands  uniting  the  diaphragm  and  convex  surface  of  the  liver,  are 
often  found  on  the  dead  body.  They  are  also  occasionally  found  between  the 
spleen  and  the  part  of  the  abdominal  parietes  with  which  its  external  surface  is 
connected.  At  the  same  time  there  is  frequently  no  trace  of  inflammation  on 
the  rest  of  the  peritoneum.  In  most  of  the  cases  where  the  autopsy  discovers 
this  partial  peritonitis,  which  we  might  call  perihepatic  or  perisplenic,  we  know 
not  whether  during  life  they  produced  any  particular  symptoms.  On  this  point 
I have  observed  the  two  following  facts  : — In  two  cases  where  close  adhesions 
35* 


414 


ANDRAL’S  MEDICAL  CLINIC. 


united  the  liver  and  diaphragm,  the  previous  history  of  the  patients  informed  us 
that  several  years  before  we  saw  them  they  had  had  jaundice.  Liver  in  its  nor- 
mal state.  In  a third  case,  jaundice  was  developed  in  a patient  during  his  stay 
in  the  hospital,  as  a complication  of  another  affection  (cerebral  congestion  with 
fever).  Death  took  place  on  the  ninth  day  after  the  appearance  of  the  jaundice. 
The  patient  had  never  complained  of  pain  in  the  site  of  the  liver.  At  the 
autopsy  we  found  interposed  between  the  liver  and  the  diaphragm  rudiments  of 
pseudo-membranes,  soft,  whitish,  and  unorganised,  which  were  evidently  of 
recent  formation.  The  duodenum  was  not  altered.  As  traces  of  the  primary 
disease,  we  found  numerous  ulcerations  at  the  end  of  the  small  intestine  and  in 
the  large  intestine.  If  we  have  elsewhere  admitted  that  simple  diaphragmatic 
pleuritis  may  occasion  jaundice  by  irritating  the  liver  sympathetically  ; a fortiori 
it  must  be  admitted,  that  jaundice  may  be  the  result  of  inflammation  of  the  por- 
tion of  the  peritoneum  surrounding  the  liver,  just  as  inflammation  of  the  pleura 
occasions  cough  by  irritating  sympathetically  the  pulmonary  parenchyma  and 
the  bronchi.  ♦ 

Another  patient  complained  of  frequent  pains  of  long  standing  in  the  right 
hy  pochondrium  ; he  never  had  had  jaundice.  After  death  we  found  the  capsule 
of  Glisson  very  much  thickened,  and  cellular  bands  extending,  on  the  one  hand, 
between  the  convex  surface  of  the  liver,  and  the  diaphragm  ; and  on  the  other 
hand,  between  the  liver  and  arch  of  the  colon.  An  individual  laboured  under  a 
double  cancer  of  the  liver  and  stomach  of  which  he  died.  Some  cellular  adhesions 
connected  the  liver  to  the  diaphragm,  and  to  the  anterior  abdominal  parietes, 
behind  which  it  was  felt  during  life.  There  was  this  remarkable  circumstance 
in  this  person,  that  he  suffered  principally  in  the  hepatic  region  when  he  walked 
down  stairs  ; is  it  because  the  cellular  bands  which  connected  the  liver  to  the 
diaphragm  underwent  a painful  dragging?  Now  it  might  be  asked,  why,  the 
same  adhesions  existing  around  the  liver,  in  one  case  they  are  not  announced 
by  any  symptom,  in  another  case  they  are  painful,  and  in  a third  they  produce 
jaundice?  But  we  can  only  answer  this  by  citing  analogous  cases,  and  showing 
that  there  is  no  constancy  in  many  of  the  symptoms  which  mark  acute  or  chronic 
inflammation  of  the  other  serous  membranes  ; thus  pleuritis  may  exist  with  or 
without  pain,  with  or  without  cough  ; thus  pericarditis,  whose  invasion  is  often- 
times announced  by  so  characteristic  a pain,  may  be  unaccompanied  with  pain 
at  its  onset,  and  remain  so  whilst  it  lasts  ; it  may  occasion  the  most  varied  modi- 
fications in  the  heart’s  contractions,  or  not  at  all  derange  them  ; thus  menin- 
gitis, its  seat  being  supposed  the  same  as  also  its  severity,  sometimes  produces 
delirium,  and  sometimes  leaves  the  intellect  intact  ; it  may  or  may  not  be 
accompanied  with  headach,  etc.  In  the  vicinity  of  the  liver,  spleen,  and  kid- 
neys, tumours  are  often  developed,  which  result  from  the  imprisonment  of  a 
certain  quantity  of  liquids  of  various  kinds  by  false  membranes,  which  form  the 
parietes  of  the  pouch,  and  which  are  the  result  of  partial  inflammation  of  the 
abdominal  serous  membrane.  These  false  membranes  have  in  general  nothing 
regular  in  their  mutual  arrangement;  they  usually  produce  within  the  pouch, 
whose  parietes  they  form,  bands,  complete  or  incomplete  septa  which  divide  it 
into  several  compartments.  At  other  times  they  are  raised,  if  I may  so  say, 
to  a higher  grade  of  organisation  : the  inner  surface  of  the  parietes  of  the  pouch 
then  presents  a regular  appearance,  smooth  or  areolated,  as  it  is  found  in  natu- 
ral cavities  ; this  pseudo-membrane,  which  was  at  first  but  an  amorphous  pro- 
duct, but  still  organisable,  becomes  changed  into  a cellulo-vascular  membranous 
tissue,  which  itself  sometimes  puts  on  the  appearance  of  a serous  or  mucous 
membrane.  Then  the  most  varied  secretions  may  take  place  in  it;  and  thus 
we  may  conceive  how  within  those  encysted  tumours,  such  different  liquids 
are  found,  serum,  pus,  and  its  numerous  varieties  ; blood,  other  products  which 
have  not  yet  received  any  especial  name,  resembling  animal  jelly,  honey,  soot, 
etc.  Hydatids  also  have  been  met  therein. 


DISEASES  OF  THE  ABDOMEN. 


415 


CHAPTER  III. 

PARTIAL  INFLAMMATION  OF  THE  PERITONEUM  OF  THE  CAVITY  OF  THE 

PELVIS. 

This  kind  of  partial  peritonitis  is  remarkable,  both  by  reason  of  the  frequent 
obscurity  of  its  diagnosis,  and  in  consequence  of  the  symptoms  to  which  it 
gives  rise.  The  cases  belonging  to  it  I shall  range  in  two  classes  : in  the  one 
those  cases  shall  be  found,  in  which  the  inflammation  of  the  pelvic  peritoneum 
during  life  produced  no  tumour  appreciable  to  the  touch  ; the  second  class  shall 
include  the  other  cases  where  there  was  a tumour  which  could  be  detected 
through  the  abdominal  parietes.  This  tumour  being  ascertained,  the  task  of 
the  observer  is  not  finished  ; he  must  determine  its  nature,  he  must  ascertain 
whether  it  belongs  simply  to  the  peritoneum,  or  to  one  of  the  pelvic  organs,  a 
perfection  of  diagnosis  which  it  is  not  always  possible  to  attain.  There  is  a 
certain  number  of  chronic  inflammations  of  the  pelvic  peritoneum,  which  are 
only  announced  by  the  pain  and  wasting  of  the  patient.  It  is  evident  that  neither 
of  these  signs  can  serve  to  discover  the  nature  of  the  affection  which  causes 
them.  The  pain  is  seldom  very  acute  : in  some  it  is  continued  ; in  others  it 
returns  only  at  intervals,  and  its  return  seems  to  be  connected  with  some  tem- 
porary exasperations  of  the  peritonitis.  In  some  cases,  where  there  was  no 
other  local  symptom  but  this  pain,  and  where  at  the  same  time  the  general 
nutrition  was  not  very  much  altered,  it  has  been  improperly  considered  as  the 
product  of  a neurosis.  I have  had  an  opportunity  of  seeing  a case  of  this  kind. 
The  subject  was  a young  woman,  who,  after  a first  confinement,  continued  to 
suffer  a pain,  which  had  its  seat  in  the  hypogastrium  behind  the  ossa  pubis,  and 
which  appeared  only  in  an  intermittent  form,  like  a neuralgia.  When  it  reap- 
peared, it  was  confined  to  the  place  already  mentioned,  and  was  but  slight ; but 
at  times  it  became  lancinating,  and  extended  as  it  were  by  irradiation  towards 
the  neck  of  the  uterus,  superiorly  towards  the  parietes  of  the  abdomen,  and 
posteriorly  in  the  lumbar  region,  where  she  said  that  she  felt  pain  like  those 
which  are  felt  at  a certain  period  of  child-birth.  Such  was  the  account  which 
she  gave  us  when  she  entered  the  Charite.  Did  not  this  affection  now  described 
resemble  a neuralgia  ? But  when  she  came  under  our  observation,  it  was  no 
longer  so  simple  an  affection.  For  the  last  month  the  pain  had  become  con- 
tinued; it  was,  however,  less  severe  than  when  it  existed  only  at  intervals. 
Pressure  on  the  hypogastrium  was  painful ; the  rest  of  the  abdomen  was  soft 
and  free  from  pain.  There  was  perceptible  emaciation,  slight  continued  fever, 
and  frequent  sweats.  We  thought  that  there  existed  a chronic  affection  of  one 
of  the  ovaries,  or  of  one  of  the  portions  of  the  peritoneum  surrounding  them. 
(Leeches  ; emollient  and  narcotic  fomentations  over  the  hypogastrium.)  This 
state  continued  for  the  next  fifteen  days  ; then  profuse  diarrhoea  set  in.  The 
entire  abdomen  became  tense  and  painful  ; she  sunk  rapidly  and  died.  The 
autopsy  detected  in  the  peritoneum  traces  of  recent  acute  inflammation,  which 
the  tension  and  general  pains  of  the  abdomen  had  announced  for  some  days  be- 
fore death  (morbid  serum  with  a mixture  of  amorphous  fibrinous  flocculi). 
The  principal  part  of  the  internal  surface  of  the  large  intestine,  as  well  as  that 
of  the  end  of  the  small  intestine,  were  very  much  injected,  a lesion  which  was 
in  accordance  with  the  diarrhoea,  which  supervened  towards  the  termination  of 
life.  These  changes  sufficiently  accounted  for  the  new  symptoms  which,  added 
to  the  primary  disease,  accelerated  the  fatal  term  ; but  what  was  the  cause  of 
the  old  hypogastric  pain  ? We  found  it  to  reside  in  a tumour  the  size  of  a small 
orange,  deeply  seated  in  the  cavity  of  the  pelvis  ; it  was  so  posited  there,  that 


416 


ANDRAL’S  MEDICAL  CLINIC. 


its  right  half  lay  between  the  body  of  the  uterus  and  the  rectum  : whilst  its  left 
half,  concealed  anteriorly  by  the  broad  ligament,  passed  laterally  beyond  these 
two  organs.  This  tumour  contained  a cavity  separated  into  several  incomplete 
apartments,  in  each  of  which  a purulent  liquid  was  found.  Its  parietes  were 
formed  of  false  membranes,  lying  one  upon  the  other,  evidently  formed  within 
the  peritoneum.  Thus  this  pain,  which  had  for  a long  time  assumed  the  cha- 
racter of  a neuralgia,  and  only  at  a later  period  appeared  to  be  connected  with 
a chronic  inflammation,  was  referable  to  an  inflammation  confined  to  a small 
portion  of  the  pelvic  peritoneum  which  set  in  imperceptibly  after  her  confine- 
ment. This  inflammation,  circumscribed  as  it  was,  became,  however,  after  a 
certain  time,  a sufficient  cause  of  fever  and  gradual  wasting.  In  another  woman 
I observed  the  same  species  of  pain,  accompanied  with  the  same  series  of 
symptoms,  and  which  also  came  on  after  a first  confinement.  However,  after 
she  had  been  suffering  for  eight  months,  all  the  symptoms  disappeared, and  she 
recovered  perfect  health. 

Tumours  similar  to  that  now  described  may  be  situate  or  developed  so  as 
to  compress  the  organs  which  they  touch,  to  impede  for  instance  the  course 
of  the  faeces  or  urine.  I have  seen  a case  where,  as  a cause  of  a constipation 
of  very  long  standing  with  progressive  wasting,  there  was  found  in  the  cavity  of 
the  pelvis  a large  pouch  full  of  pus,  developed  in  the  peritoneum  with  hard 
parietes,  and  as  it  were  fibrous  ; it  occupied  the  place  of  the  rectum,  which, 
being  flattened  on  it  like  a riband,  deviated  considerably  to  the  right,  and  was 
no  longer  connected  with  the  sacrum.  The  parietes  of  the  intestine  were  not 
altered  ; but  it  is  hard  to  think  that  if  the  individual  had  lived  for  a longer 
period,  the  rectum  would  not  have  undergone  some  lesion  of  texture,  compressed 
and  irritated  as  it  was  by  the  pressure  of  the  tumour  which  had  displaced  it. 
It  might  then  have  happened  that  by  means  of  a fistula  set  up  between  the 
cavity  of  the  tumour  and  that  of  the  rectum,  the  pus  would  have  been  discharged 
by  the  anus,  and  a cure  would  have  been  effected.  One  would  have  thought 
during  life  that  there  was  scirrhous  hardening  of  the  parietes  of  the  rectum. 

I have  seen  another  case  in  which  the  cavity  of  the  bladder  was  almost  en- 
tirely effaced  by  the  pressure  of  a tumour,  in  which  was  a cavity  full  of  pus  and 
of  debris  of  hydatids.  Being  developed  between  the  bladder  and  rectum,  it  had 
pushed  the  posterior  wall  of  the  former  before  it  so  much,  that  this  wall  almost 
touched  the  orifice  of  the  urethra.  The  two  ureters  being  distended  by  a great 
quantity  of  urine,  had  nearly  acquired  the  size  of  a small  intestine. 

These  different  species  of  partial  peritonitis  exist  less  frequently  alone  than  as 
a complication  of  certain  affections  of  organs  contained  in  the  pelvis,  and  par- 
ticularly of  the  uterus  and  ovaries.  Thus,  in  some  cases  of  chronic  metritis, 
we  find  around  the  uterus  one  or  more  abscesses,  which  are  evidently  seated 
in  the  peritoneum. 

Partial  inflammations  of  the  pelvic  peritoneum,  which  have  occasioned  puru- 
lent depositions,  circumscribed  by  false  membranes  more  or  less  organised,  have 
in  general  a fatal  termination.  Death  may  follow  the  constantly-increasing 
wasting  of  the  patient ; a striking  proof  of  the  fatal  influence  exercised  over 
nutrition  and  life  by  a chronic  inflammation  of  small  extent,  and  which  is  not 
seated  in  any  important  organ.  A priori,  one  would  not  suppose  that  anything 
serious  could  result  from  the  collection  of  a small  quantity  of  pus,  in  the  midst 
of  false  membranes  partially  secreted  by  the  peritoneum,  the  rest  of  this  mem- 
brane remaining  intact,  and  no  other  organ  being  affected.  But  if  this  partial 
inflammation  is  sufficient  to  disturb  the  circulation,  to  alter  nutrition,  to  deprive 
the  individual  of  his  physical  and  moral  energy,  it  seldom  happens  that  it  proves 
fatal  by  itself.  Death  generally  supervenes,  when,  after  the  exhausted  state 
into  which  the  patient  has  already  fallen,  a new  inflammation  sets  in  : some- 
times it  is  the  peritonitis,  which,  from  having  remained  partial  for  a long  time, 


DISEASES  OF  TIIE  ABDOMEN. 


417 


suddenly  becomes  general;  sometimes  different  organs  come  to  be  affected, 
and  particularly  the  lungs  or  digestive  tube  ; for  the  peculiar  facility  with  which 
these  two  organs,  and  principally  the  latter,  come  to  be  attacked  with  inflam- 
mation, in  the  course  or  towards  the  end  of  every  chronic  disease,  is  a very  re- 
markable circumstance.  It  is  much  more  frequently  by  these  complications,  than 
by  the  chronic  disease  itself,  that  the  patient  is  carried  off. 

The  pus  collected  in  any  part  of  the  cavity  of  the  pelvis  sometimes  makes  its 
exit  externally,  and  then  either  a cure  is  effected,  or  the  suppuration  still  con- 
tinuing, and  the  inflammation  not  ceasing,  the  disease  terminates  fatally.  A 
woman  had,  in  the  right  side  of  the  hypogastric  region,  a large  hard  uneven 
tumour,  somewhat  painful.  During  the  three  first  months  of  her  stay  in  the 
hospital  this  tumour  remained  stationary.  After  this  she  passed,  for  the  first 
time  by  stool,  a great  quantity  of  purulent  matter.  On  the  following  days  she 
passed  more  ; then  the  purulent  discharge  ceased,  but  afterwards  it  reappeared 
several  times.  From  the  first  day  that  this  discharge  of  pus  took  place  the  size 
of  the  tumour  diminished  ; it  then  remained  stationary  again.  The  patient 
found  herself  better,  and  left  the  hospital. 

It  is  probable  that  the  purulent  stools  which  this  woman  had  were  connected 
with  the  hypogastric  tumour,  and  that  it  was  the  matter  contained  in  this  that 
made  its  escape  through  the  rectum  ; for,  when  pus  is  secreted  by  the  mucous 
membrane  of  the  large  intestine,  it  never  makes  its  exit  by  the  anus  in  such  large 
quantity  ; and  farther,  it  must  not  be  forgotten  that  this  discharge  of  pus  coincided 
with  a sudden  diminution  of  the  size  of  the  tumour. 

Are  these  cases  where  the  pus  collected  in  some  part  of  the  pelvic  peritoneum 
may  be  reabsorbed,  pass  into  the  veins,  then  be  eliminated  from  the  mass  of 
blood,  either  gradually  and  imperceptibly,  or  so  as  to  form  purulent  depositions 
within  the  substance  of  different  organs.  On  this  point  we  shall  submit  to  the 
reader  a curious  fact,  in  whatever  manner  he  may  please  to  interpret  it. 

A woman  died  in  the  Charite  a little  time  after  her  accouchement.  Her  labour 
had  been  extremely  difficult.  During  her  stay  in  the  hospital  she  presented  two 
different  periods.  The  first  was  characterised  by  dull  pains  in  the  hypogastrium, 
continued  fever,  with  profuse  sweats  every  night ; rapid  wasting  away.  The 
second  period  was  marked  by  a state  of  prostration,  which  did  not  set  in  gradually, 
by  a sudden  alteration  in  the  features, some  delirium,  and  profuse  diarrhoea.  This 
second  period  was  short,  and  was  soon  followed  by  death.  At  the  autopsy  the 
following  lesions  were  found  : — first,  a state  of  engorgement,  and  softening  of 
the  tissue  of  the  uterus  ; secondly,  around  this  organ  several  purulent  collections 
inclosed  in  compartments,  the  parietes  of  which  consisted  of  false  membranes 
intercrossing  in  different  directions  ; thirdly,  a little  serum,  which  was  slightly 
turbid,  effused  into  the  rest  of  the  peritoneum;  fourthly,  considerable  injection 
of  the  end  of  the  ileum,  caecum,  and  commencement  of  the  colon;  fifthly, 
a more  uncommon  lesion,  to  which  I particularly  call  attention  at  this  moment. 
A great  number  of  veins,  situate  in  the  cavity  of  the  pelvis,  struck  us  by  their 
state  of  distention  ; they  were  filled  with  coagulated  blood,  with  which  a whitish 
liquid  was  mixed  in  the  form  of  drops  scattered  to  and  fro,  which  the  persons 
present  at  the  autopsy  compared  to  pus.  The  parietes  of  these  veins  presented 
no  appreciable  alteration.  The  blood  contained  in  the  primitive  iliac  vein,  and 
in  the  vena  cava  inferior,  presented  the  same  appearance.  Nothing  similar  to 
this  was  found  in  the  right  cavities  of  the  heart,  nor  in  the  remainder  of  the 
circulatory  apparatus.  But  in  cutting  into  the  right  lung,  which,  when  viewed 
externally,  appeared  very  healthy,  its  parenchyma  was  found  to  be  compressed 
in  three  different  points  by  collections  of  pus  occupying  a space,  which,  for  two 
of  them,  might  contain  a walnut,  and  for  the  third  a hazel-nut.  Around  these 
abscesses  the  pulmonary  parenchyma  presented  no  appreciable  alteration.  In 
the  liver  another  abscess  was  found,  which,  like  those  of  the  lung,  existed  with- 


418 


ANDRAL’S  MEDICAL  CLINIC. 


out  any  lesion  of  the  parenchyma  around  it.  Lastly,  in  the  brain,  on  the  level 
of,  and  external  to  the  optic  thalami,  we  found  another  abscess,  the  size  of  a 
large  hazel  nut,  which  was  not  accompanied  by  any  injection,  nor  by  any  soft- 
ening of  the  surrounding  cerebral  substance. 

I have  observed  other  facts  similar  to  the  preceding  with  respect  to  those  puru- 
lent collections  found  simultaneously  in  different  organs  without  any  trace  of 
inflammation  of  the  latter.  It  is  principally  after  capital  surgical  operation,  diffi- 
cult labours  followed  by  metritis,  and  suppurations  a long  time  kept  up,  that  I 
have  seen  such  cases.  In  the  particular  fact  now  under  consideration,  does  it 
not  appear  that  the  pus,  primarily  formed  in  the  cavity  of  the  pelvis,  was  ab- 
sorbed, carried  into  the  veins  where  it  was  found,  intimately  mixed  in  the  heart 
with  the  rest  of  the  blood,  where  it  was  no  longer  possible  to  perceive  it,  then 
deposited  in  the  parenchyma  of  the  lung,  liver  and  brain.  In  the  same  manner 
as  in  experiments  on  animals,  we  see  several  substances  introduced  into  the 
cellular  tissue  become  mixed  with  the  blood,  and  separated  from  it  on  the  sur- 
face, or  in  the  parenchyma  of  different  organs. 

PARTIAL  INFLAMMATION  OF  THE  SUBPERITONE AL  CELLULAR  TISSUE. 

We  shall  now  speak  of  those  inflammations  after  the  different  cases  of  partial 
peritonitis  which  have  been  described,  as  this  will  in  fact  serve  as  a complement 
to  their  history.  First,  the  symptoms  of  most  of  the  affections  of  the  subperi- 
toneal  cellular  tissue  are  confounded  with  the  symptoms  of  the  diseases  of  the 
peritoneum  itself ; in  the  next  place,  the  researches  of  MM.  Ribes  and  Gendrin 
show  that  there  is  but  little  difference,  with  respect  to  texture,  between  the  peri- 
toneum, properly  so  called,  and  the  cellular  tissue  subjacent  to  it,  and  that  it  is 
beneath  this  cellular  tissue  that  several  of  the  physiological  or  pathological  phe- 
noma  take  place,  whose  exclusive  seat  is  ordinarily  placed  in  the  thin  membrane 
called  peritoneum. 

Case  13. — Tumour  developed  beneath  the  gastro-hepatic  epiploon,  which,  by  reason  of  its 
situation,  and  the  symptoms  produced  by  it,  might  be  taken  for  a tumour  of  the  liver  and 
stomach — Jaundice. 

A mason,  seventy-one  years  of  age,  fell  on  his  loins  in  the  month  of  July, 
and  was  obliged  to  keep  his  bed  for  some  days  ; he  then  resumed  his  ordinary^ 
occupation.  In  the  October  of  the  same  year  he  began  to  feel  slight  and  tem- 
porary pain  in  the  right  portion  of  the  epigastrium.  This  pain  became,  by 
degrees,  more  severe  and  continued.  At  the  same  time  he  lost  appetite  ; he 
vomited  some  acid  liquids  ; there  was  constipation  ; diminution  of  strength  ; 
emaciation;  gradual  development  of  a tumour  in  the  right  hypochondrium. 
On  the  25th  of  December  he  entered  the  Charite,  and  presented  the  symptoms 
now  mentioned.  To  the  right  of  the  epigastrium  there  was  a tumour  which 
extended  about  five  fingers’  breadth  below  the  edge  of  the  ribs  ; it  was  globular, 
immoveable,  and  very  painful  on  pressure.  The  face  presented  a marked 
straw-coloured  tint ; appearance  of  the  tongue  natural;  pulse  weak,  not  fre- 
quent ; skin  dry  and  rough.  December  28th,  a very  marked  jaundice  tint  on 
the  conjunctivae  and  over  the  entire  skin.  29th,  some  disturbance  in  the  intel- 
lectual functions  ; face  very  much  altered.  He  sunk  rapidly,  and  died  on  the 
1st  of  January. 

Post-mortem.  The  abdominal  parietes  having  been  raised,  we  observed, 
towards  the  right  of  the  epigastrium,  a tumour  which  was  about  the  size  of  two 
fists  put  together  ; it  was  circumscribed  inferiorly  by  the  small  curvature  of  the 
stomach,  connected  superiorly  with  the  left  lobe  of  the  liver  and  diaphragm,  pos- 
teriorly resting  on  the  aorta.  It  adhered  firmly  to  the  diaphragmatic  edge  and 
posterior  surface  of  the  stomach,  and  projected  considerably  into  the  interior  of 


DISEASES  OF  THE  ABDOMEN. 


419 


this  organ  at  its  pyloric  portion.  No  morbid  change  in  the  structure  of  the 
stomach.  This  tumour  consisted  of  scirrhous  and  encephaloid  tissues  in  the 
crude  state,  with  deposition  of  tuberculous  matter  in  some  points.  This  tumour 
did  not  seem  to  press  on  the  biliary  ducts.  The  first  portion  of  the  duodenum 
was  healthy,  but  the  other  two  portions  of  this  intestine  presented  intense  redness. 
The  orifice  of  the  ductus  choledochus  was  marked  by  a red  tubercle  much  more 
prominent  than  usual.  In  the  first  convolutions  of  the  jejunum  the  traces  of 
inflammation  disappeared  gradually. 

This  individual  presented,  during  life,  all  the  rational  signs  of  an  organic  affec- 
tion of  the  stomach,  and  it  was  natural  to  consider  the  tumour  as  connected  with 
this  organ.  Yet  this  diagnosis  was  not  just.  The  stomach  was  healthy,  but  the 
compression  to  which  it  was  subjected  by  the  tumour  developed  in  its  vicinity  ; 
the  obliteration  of  a portion  of  its  cavity  by  this  tumour,  sufficiently  account  for  the 
different  symptoms  of  chronic  gastritis  which  the  patient  presented.  With 
respect  to  the  origin  of  this  tumour,  I shall  merely  remark,  that  it  is  possible 
that  the  fall  on  the  loins,  that  is  to  say,  an  irritating  cause,  contributed  to  pro- 
duce it ; and  with  respect  to  its  nature,  I consider  it  as  the  product  of  hyper- 
trophy and  induration  of  the  cellular  tissue.  There  was  no  lesion  of  the  liver 
or  encephalon  to  account  for  the  new  symptoms  which  appeared  during  the 
termination  of  the  patient’s  life,  namely,  the  jaundice  and  cerebral  phenomena. 
There  was  very  well  marked  inflammation  of  the  duodenum,  with  tumefaction 
of  the  mucous  membrane  around  the  orifice  of  the  duct  for  the  excretion  of  bile. 

Case  14. — Abscess  in  the  psoas  muscle,  with  the  destruction  of  the  periosteum  of  the  vertebrae 
in  contact  with  the  pus — Ascites. 

A painter,  forty-five  years  of  age,  had  several  times  undergone  treatment  for 
lead  colic  in  the  Oharite.  He  came  to  the  hospital  again  complaining  of  abdo- 
minal pain,  which  he  referred  as  usual  to  his  handling  preparations  of  lead  ; but 
we  were  soon  convinced  that  they  were  referrible  to  another  cause.  Here,  in 
fact,  was  what  we  ascertained  : four  months  previous  to  his  entering  the  hos- 
pital this  person  began  to  feel  in  the  lumbar  region,  particularly  in  the  left,  a 
deep-seated  pain,  which  was  not  increased  by  pressure,  but  which  was  increased 
by  walking  and  by  different  movements  of  the  trunk.  During  the  first  three 
months  he  continued  his  usual  occupation,  though  with  considerable  pain  ; but 
after  this  time  the  lumbar  pain  extended  to  the  abdomen  ; walking  was  now 
impossible,  and  soon  after  the  abdomen  began  to  swell.  When  we  saw  him  he 
evidently  had  ascites  ; the  two  lower  extremities  also  were  infiltrated  as  well  as  the 
scrotum,  face  pale  and  emaciated  as  well  as  the  upper  extremities  ; pulse  frequent, 
skin  hot.  The  left  thigh  immoveable  and  semiflexed  ; when  he  attempted  to  move 
it  the  pains  in  the  abdomen  and  loins,  on  the  leftside,  became  very  intense  ; he 
could  raise  it  on  the  contrary  without  increasing  the  pain.  He  sweated  profusely 
every  night ; had  had  a cough  for  some  months,  and  expectorated  greenish  and 
opaque  sputa.  He  remained  three  months  in  the  hospital  without  any  improve- 
ment ; then  a large  eschar  formed  on  the  sacrum,  which  nothing  could  arrest ; 
one  of  the  thighs  was  attacked  with  erysipelas  ; the  patient  fell  into  an  adynamic 
state,  and  soon  died.  During  the  last  period  of  his  life,  his  expectoration  resem- 
bled that  of  consumptive  patients ; in  the  midst  of  a fluid  like  gum-water, 
greyish  flocculi  were  suspended. 

Post-mortem.  A considerable  quantity  of  limpid  serum  in  the  peritoneal 
cavity.  There  was  nothing,  anatomically  speaking,  to  indicate  that  this  ascites 
had  succeeded  peritonitis.  Beneath  and  outside  the  layer  of  peritoneum,  which 
is  reflected  from  the  kidneys  over  the  left  side  of  the  vertebral  column  to  form 
one  of  the  folds  of  the  mesentery,  there  was  an  enormous  collection  of  pus. 
It  occupied  the  place  of  the  psoas  muscle,  of  which  a few  scattered  fibres  only 


420 


ANDRAL’S  MEDICAL  CLINIC. 


were  found,  which  terminated  inferiorly  in  its  tendon,  which  still  continued 
intact.  The  pus  was  in  immediate  contact  with  the  body  of  the  vertebrae,  which 
were  stripped  of  their  periosteum  and  rough.  Some  pus  was  also  found 
beneath  the  crural  arch ; a great  quantity  of  it  between  the  muscles  of  the  inner 
part  of  the  thigh.  The  mucous  membrane  of  the  stomach  was  of  a slate  colour. 
The  rest  of  the  digestive  tube  was  slightly  injected  in  some  points.  The 
bronchi  were  red,  the  pulmonary  parenchyma  was  engorged,  but  contained  no 
tubercles.  The  gangrenous  ulceration  of  the  skin  of  the  sacrum  had  exposed 
a part  of  this  bone. 

This  case  presents  an  instance  of  a disease  some  years  ago  called  psoitis.  It 
appears  to  me  at  least  doubtful  that  the  disease  commenced  by  an  affection  of  the 
muscle  itself.  We  scarcely  ever  see  mere  muscular  rheumatism  terminate  in 
suppuration  ; that  which  occurred  in  this  case  appears  rather  to  have  had  its 
origin  in  inflammation  of  the  sub-peritoneal  and  intermuscular  cellular  tissue  of 
this  part,  which  had  gradually  set  in.  It  was  for  a long  time  announced  by  no 
other  symptom  than  lumbar  pain.  The  destruction  of  the  psoas  muscle,  in  the 
middle  of  which  the  pus  was  found,  was  not  consecutive  on  the  inflammation 
of  the  cellular  tissue,  its  fibres  disappeared  by  little  and  little,  as  the  periosteum 
of  the  bodies  of  the  vertebrae  did.  The  immobility  of  the  thigh  of  the  affected 
side,  the  extreme  pain  produced  by  every  attempt  to  move  it,  have  been  noticed 
as  symptoms  of  psoitis  ; these  phenomena  were  very  well  marked  in  this  patient. 
The  ascites,  and  infiltration  of  the  scrotum  and  lower  extremities,  were  consecu- 
tive on  the  sub-peritoneal  abscess.  Did  they  depend  on  it?  At  least  no  other 
cause  was  found  to  which  they  could  be  attributed.  I have  stated  elsewhere 
what  importance  should  be  attached  to  the  characters  of  the  sputa  in  order  to 
diagnose  the  existence  of  pulmonary  tubercles.  Here  we  observed  for  several 
days  those  flocculent  sputa,  which  some  persons  consider  characteristic  of 
phthisis,  and  yet  there  was  nothing  here  but  simple  chronic  bronchitis.  This 
had  been  in  existence  for  a considerable  time,  and  yet  no  tubercle  was  formed 
in  the  lung ; there  was  not  then  any  disposition  to  tuberculous  secretion  ; which 
was  strictly  in  accordance  with  the  nature  of  the  pus  formed  under  the  lumbar 
peritoneum ; it  was  creamy,  homogeneous,  and  not  separated  into  lumps,  more 
or  less  serous,  as  it  is  generally  found  in  persons  disposed  to  tubercles;  so  true 
is  it  that  the  local  action  which  produces  tubercle  is  connected  with  a general 
disposition  of  the  solids  and  fluids,  which  manifests  itself  by  remarkable  modifi- 
cations in  the  process  of  nutrition  and  secretion. 


THE  END. 


■ 


. 


' 


J 


